Published on May 19, 2016
Can adjusting my Pomalyst+dex dosages be beneficial to my blood counts? Viewer, Henry, asks Dr. Jadin Shah of MD Anderson Cancer Center, this Ask the Expert question. Dr. Shah responds with a question of his own, "After that one week off that you're off the Pomalyst, does your white count recover?" Dr. Shah goes on to explain neutrophil count, ANC and response rate of pomalidomide in varying doses.
This Ask the Expert series is sponsored by the Patient Empowerment Network, which received funding from Celgene, Novartis and Takeda.
Transcript | How Does Adjusting the Dose of My Myeloma Treatment Affect Blood Counts?
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Here is a question we got from Henry. Henry writes, "I was in complete remission with multiple myeloma for seven-and-a-half years on the maintence drug, Revlimid, until it stopped working for me. In August 2015, I was put on another drug, Pomalyst with dex[amethasone], and I'm currently I’m still on those drugs.My numbers are going down in the right direction, but my white blood count is currently 2.3. One hematologist wants to reduce my dose from 3 milligrams to 2 milligrams; the other wants to leave it at 3. What’s the difference to you, and how could this be beneficial?
That’s a great question. I think there [are] a couple of things, here. One, you told us the white count is 2.3, but it’s important to also know what the neutrophil count is, as well. There [are] lots of different cells that make up the white blood cell count, from neutrophils to lymphocytes. And so I think it’s important to know what the ANC—it’s a term that we’ll often use—or neutrophil count, because that’s really more important to identify what your risk of infection is.
If your ANC is lowand less than 1 or 1.0, then that means that you’re a little bit higher risk of infection and a lower, then the more concerned we are. so that becomes more helpful than just the white count to really understand what the effects of the Pomalyst may be and what we need to do or not to do.
So that’s the first question. The second issue is around the dosing of the Pomalyst. So Pomalyst is approved right now in the U.S. at 4 milligrams, and we can dose reduce down to 3 milligrams or 2 milligrams as needed. However, there’s some very nice data from the Mayo Clinic group as well, where they looked at 2 milligrams of pomalidomide and when you look across different trials, it appears that if you’re on 2 or 4, the response rates are pretty similar.
So one group of physicians may think that the 2 milligram does is really identical to 4 milligrams in terms of how active it is. And we may get less side effects and less drops in your blood counts with the 2-milligram dose. So that may be one rationale to go down to 2 milligrams.
However, at the end of the day if you’re having an excellent response to the therapy that you’re on now, and your ANC is above 1, then I personally would just continue with exactly what you're doing now because you have a drug that’s working, a dose that’s working. And if your ANC is above 1, you’re tolerating it well otherwise, then I would continue as you are.
Now, it also depends upon when you measure that white count. Because we know that at the end of the 21 days that you’re taking the Pomalyst, that’s when we’re going to expect to see your nadir at the lowest time of that—lowest white count that we’ll see. What I'm also concerned is after that one week off that you’re off the Pomalyst, does your white count recover? As long as it recovers back to the normal range and we’re not having recurrent infections, then I think it’s perfectly fine to continue with your 3-milligram dose.
But if you measured your white count at the very nadir at the end of the 21 days when I expect the count to be lowest, then I think that’s reasonable and expected and I wouldn’t necessarily make any changes in the dose based on that. So I think that’s important, as well.