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Can Older Patients with Multiple Myeloma Stop Taking Steroids?

Can Older Patients with Multiple Myeloma Stop Taking Steroids?
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Published on March 30, 2021

Dexamethasone: Is it Always Necessary for Treatment?

Older patients with multiple myeloma may be able to avoid long-term use of the steroid dexamethasone, which is generally given in combination with lenalidomide (Revlimid) to treat this type of blood cancer. 

A recent study published in Blood found that switching select older patients to a lower dose of lenalidomide and discontinuing dexamethasone after nine months was safe and produced similar results compared to those who continued to receive the combination treatment.

"Myeloma patients are a very diverse population, including fit patients who may tolerate full-dose treatments, and intermediate-fit and frail patients who are more susceptible to adverse events that may negatively affect the duration and outcome of treatment due to the presence of comorbidities and functional impairments, thus requiring an adapted therapy," lead author Dr. Alessandra Larocca, of the University of Turin in Italy, said in a press release.

She added: "Our study shows, for the first time, that reducing the dose or intensity of treatment is a feasible option and produces similar outcomes as standard dose treatments for intermediate-fit patients."

Treating Multiple Myeloma with Lenalidomide and Dexamethasone

Lenalidomide-dexamethasone (Rd) is considered standard treatment for elderly patients with multiple myeloma and is typically given until the disease progresses, or they are unable to tolerate the therapy, according to Dr. Larocca. Older patients are more susceptible to side effects because they are more likely to have other health conditions.

Dexamethasone, which is often combined with other medications, has been associated with insomnia, anxiety, agitation, weight gain and edema in the legs. "Prolonged steroid use is scarcely tolerated in the long term, even in younger patients, and patients may often require dose reduction or interruption," Dr. Larocca said.

The trial involved 33 medical centers in Italy and included patients with newly diagnosed multiple myeloma (median age 76) who were intermediate-fit for treatment, either because of their age or functional impairments (such as being unable to bathe or dress).

A total of 199 patients were enrolled and randomized between October 2014 and October 2017 to receive continuous Rd or a dose/schedule-adjusted Rd followed by maintenance 10 mg/day without dexamethasone (Rd-R).

After a median follow-up of 37 months, those who were no longer taking dexamethasone experienced a significantly longer period without a medical problem or relapse compared with those who continued on the standard Rd therapy (10.4 months vs. 6.9 months, respectively).

Patients in the Rd-R group also went longer without their disease getting worse (20.2 months vs. 18.3 months). Nearly 75% were alive after three years, compared to 63% in the continuous Rd group.

The tailored approach was also better tolerated and resulted in fewer adverse effects, with the most common being low white blood cell counts, infections and skin disorders.

Moving Forward

While a recent study found that autologous hematopoietic stem cell transplants (HSCT) are effective for older patients with multiple myeloma, not everyone will be a candidate. Dr. Larocca estimates that about one-third of those who are ineligible for stem cell transplants fit the criteria used in this study. If those patients can be spared long-term steroid use without sacrificing their prognosis, they may be able to improve their quality of life.

"We expect the results of this study may help to improve and optimize the treatment of elderly patients who may be at greater risk of treatment toxicity and poor survival due to their age or comorbidities," she said.

-Megan Trusdell

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