Case Study 2 - Question 2 | FocusOn Oncology

Decision 2

Patient history: Samuel, a 79-year-old patient with MM, returns for an oncology consultation at 9 months after the initiation of DRd. He is considered ineligible for autologous stem cell transplantation. The patient achieved partial response (PR) at month 6 and very good partial response (VGPR) at month 8. He has continued treatment with DRd, with a reduced dexamethasone dose of 12 mg/week. Samuel developed an upper respiratory infection 2 months after initiation of therapy, which resolved after treatment with levofloxacin. He has continued thromboprophylaxis, herpes zoster prophylaxis, and trimethoprim/sulfamethoxazole for the duration of the DRd treatment.

Comorbidities: Type 2 diabetes mellitus, controlled with medications and diet. Samuel is underweight and his daily functioning status is consistent with baseline (ECOG performance status II).
Current presentation: Laboratory results show that Samuel has maintained VGPR. His anemia and hypercalcemia resolved after treatment with DRd was initiated. Chemistry values indicate deterioration of renal function (CrCl: 45 mL/min, serum creatinine: 2.0 mg/dL). Hematology results indicate thrombocytopenia (platelets: 65,000 per mcL).
Challenge: Samuel complains about adverse reactions related to his treatment regimen, including increased fatigue, lower extremity edema, and difficulty urinating. His primary care provider is concerned about the risk of chemotherapy-induced renal failure and hematologic complications, and has referred Samuel for an oncology consultation.

Choose your next step:

a. Continue daratumumab and dexamethasone, discontinue lenalidomide

b. Continue DRd, reduce lenalidomide dose, stop thromboprophylaxis

c. Stop DRd and monitor the patient

d. Continue daratumumab and dexamethasone, stop lenalidomide and thromboprophylaxis, initiate bortezomib