COVID-19 and Multiple Myeloma: Frequently Asked Questions
Please review ASH's disclaimer regarding the use of the following information. The FAQs available on this page are not being regularly updated. The information contained herein is only accurate as of the date listed, which represents the last time the information was reviewed by experts. For the latest information on COVID-19 treatments, please review ASH’s COVID resources; previously available resources can be accessed via the archives.
(Version 2.1; last updated January 22, 2021)
Input from S. Vincent Rajkumar, MD; Michele Cavo, MD; Joseph Mikhael, MD, FRCPC, Med; Maria-Victoria Mateos, MD, PhD; Graham Jackson, MBBS, FRCP, FRCPath, MA, DM; Philippe Moreau, MD; Paul Richardson, MD; and Binod Dhakal, MD.
Note: Please review ASH's disclaimer regarding the use of the following information.
Are you changing your approach to initial therapy?
Multiple myeloma patients with active disease need treatment to avoid morbidity and mortality, despite the COVID-19 pandemic; however, treatment can be individualized to limit additional exposure to COVID-19. For example, we recommend starting triplet therapy with bortezomib, lenalidomide and dexamethasone (RVD) for 6- 12 cycles followed by lenalidomide maintenance in patients requiring treatment, and bortezomib can be added to this every 2 weeks for high risk patients as outlined below. Elderly myeloma patients could start with RVD or daratumumab-Rd (DRd) depending on cytogenetic risk and other comorbidities, and if necessary, can be continued on Rd only after achieving best response. Weekly bortezomib may have practical advantages (versus bi-weekly) during induction with a monthly schedule used (vs 3 weekly).
Are you changing your recommendations for maintenance therapy?
As the risk of myeloma relapse is higher without treatment, we don’t recommend stopping maintenance therapy. Extended access to lenalidomide can be provided to patients for up to 2 months at a time, with telemedicine check-ins and in-home blood draws as required before starting a new cycle. For high risk patients on RVD maintenance, we recommend continuing therapy with RVD, but it can be changed to Rd if appropriate. If a patient gets COVID, it is prudent to interrupt maintenance until resolution of infection.
Are you changing therapy to minimize visits? For example, changing to oral and less frequent regimens? For example: how frequently are you giving zometa infusions?
Whenever possible it is recommended to use weekly and oral regimens as noted above. Patients on three drug regimens can be continued with doublet oral regimens during the COVID-19 pandemic, especially in those with stable disease and with standard risk cytogenetics. Outpatient visits for treatment are restricted to patients in whom benefits of multidrug non-oral regimens are expected to outweigh the risks. Patients receiving bisphosphonates should be changed to zometa every 3 months or this drug class can be held during this pandemic. Remote labs, telemedicine, and prescription delivery via mail should be used to decrease clinic visits.
Are you holding clinical trial enrollment for relapsed and/or refractory myeloma patients during this outbreak? How are you treating patients in such cases?
Most clinical trials, including cellular therapy trials, that were on hold during the COVID-19 pandemic are now starting to enroll patients again. This includes clinical trials that are testing drugs which have shown early clinical activity in myeloma (especially for patients with no other therapeutic alternatives) and also which have an all oral approach and /or minimize infusion room visits. It is recommended that patients be screened for SARS-CoV-2 before receiving any investigational drugs. Alternatively, patients with heavily treated disease who cannot be enrolled in clinical trials can be considered for novel drugs with compassionate use programs or expanded access if available. Investigators should work with the IRB, companies and agencies to get waivers to minimize visits for patients on clinical trials.
How are you managing transplant-eligible patients?
For transplant-eligible myeloma patients, delaying the stem cell transplant (including HSPC collection and storage) may be prudent if there are resource issues due to COVID. In such cases, continued RVD induction for 6 and up to 12 cycles can be considered. Patients who are already in the process of stem cell collection can proceed with stem cell collection. In the absence of resource and capacity issues, it is recommended that patients proceed to stem-cell transplant-based therapy specially in high-risk myeloma. Patients should be screened for SARS-CoV-2 before the procedure.
Should I give my patients with myeloma a SARS-CoV-2 vaccine?
As patients with myeloma have a 7-10 fold increased risk of bacterial and viral infections, all appropriate measures should be exploited to vaccinate against a broad range of pathogens, including SARS-CoV-2. The timing of the vaccination may vary depending on the patient and treatment status and we recommend following the IDSA guidelines. For more information, see the ASH FAQs about SARS-CoV-2 vaccines and immunocompromised patients.
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