Case Study: How Would You Treat…

Decision 1

Case description: Mindy, a 76-year-old retired store owner, was diagnosed with multiple myeloma (MM) 9 months ago, after presenting with lower back and neck pain. Mindy has a good support system and is moderately active. Her ECOG performance status has remained at 1 since diagnosis. ISS disease stage is II.

Therapy: Mindy is considered ineligible for autologous stem cell transplantation and has been treated with daratumumab/lenalidomide/dexamethasone (DRd) for the past 9 months; adherence to lenalidomide (25 mg daily) is 90% and adherence to daratumumab s.c. (Darzalex Faspro) is 100%. She achieved partial response (PR) at month 1 and very good partial response (VGPR) at month 6.
Comorbidities: early-stage Parkinson’s disease, well controlled with medication.
Current presentation: Mindy presents with fever and dyspnea; she is hospitalized with a diagnosis of pneumonia (grade 3), which resolves after 1-week treatment with levofloxacin. Laboratory results show that chemistry values are stable, reflecting VGPR; hematology results show grade 3 neutropenia, which has been recurrent since the beginning of therapy; hypogammaglobulinemia (IgG < 400) has persisted for the past 6 months. No new findings have been detected on imaging tests.
Challenge: The patient is concerned about her risk for recurrent infections. Her primary care provider has explained that the neutropenia and hypogammaglobulinemia increase her risk for respiratory infections. However, Mindy would like to continue therapy, to achieve complete response (CR) and maintain remission.

Choose your next step:

a. Continue treatment with DRd and support with pegfilgrastim (Neulasta)

b. Stop DRd, treat with intravenous immunoglobulin (IVIG), and monitor progression

c. Continue treatment with DRd but reduce lenalidomide dose

d. Stop daratumumab and continue lenalidomide/dexamethasone

Decision 1

Decision 1

Choose your next step:

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