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Multiple Myeloma Drugs and Chemotherapy

The ultimate goal is curing multiple myeloma, but current drugs cannot completely eliminate the disease. Drugs can be used to control multiple myeloma, like insulin is used for diabetes.

Doctors at Memorial Sloan Kettering use several classes of drugs to treat multiple myeloma. These include proteasome inhibitors, immune-modulating drugs, and chemotherapies. Two, three, or four drugs can be combined to get the best results.

Increasing the number of drugs in a combination can improve their effectiveness. This does increase the chance of side effects, however. Side effects may include nausea, fatigue, rashes, or more serious conditions, such as shortness of breath and seizures. Researchers at Memorial Sloan Kettering are working to determine the best drug combinations and how to use them most effectively.

Most people with myeloma first have intensive treatment to lessen the disease. This is called induction treatment. It often includes a combination of drugs and high-dose chemotherapy. When needed, those are followed by autologous stem cell transplantation (in which your own stem cells are used). After the intensive phase, the majority of people continue a maintenance treatment, often with a single drug.

Proteasome Inhibitors

In 2003, the Food and Drug Administration approved bortezomib (Velcade®) for multiple myeloma. The proteasome is a complex of enzymes found in cells that normally regulates the removal of defective proteins. Bortezomib blocks that activity, which is why this type of drug is called a proteasome inhibitor. It causes defective proteins to build up and die. Myeloma cells seem to be more sensitive than normal cells to this effect, although some healthy cells can be harmed.

Bortezomib was the first proteasome inhibitor approved to treat patients who had already been treated with two other types of chemotherapy and whose cancer has still progressed after the most recent therapy. Then, in 2008, partly as a result of clinical trials led by MSK investigators, bortezomib was approved for use against multiple myeloma in the initial phase of treatment, because it was shown to be very effective in these cases. Bortezomib is in commonly combined with other drugs called lenalidomide and dexamethasone.

Carfilzomib (Kyprolis®) is a newer proteasome inhibitor available to multiple myeloma patients. At MSK, carfilzomib is often used as first-line therapy in combination with lenalidomide and dexamethasone for people who can tolerate this combination. Carfilzomib can be effective when bortezomib or other treatments have proven ineffective, or when multiple myeloma has returned after an earlier treatment.

Immune-Modifying Drugs

Immune-modifying drugs can be used to help the immune system fight the cancer cells or to keep them from multiplying. Our doctors use three immune-modifying drugs to treat multiple myeloma: thalidomide, lenalidomide, or pomalidomide. They are taken as pills and are usually combined with another drug, such as dexamethasone.

Thalidomide was first used in the late 1950s as a sedative and to combat nausea during pregnancy. It was banned for decades after it was found to cause birth defects. In the late 1990s, however, cancer researchers discovered that thalidomide is an effective treatment for multiple myeloma. It helps people who are newly diagnosed and helps keep the myeloma from returning in people whose disease has been brought under control. Thalidomide is also given to people with multiple myeloma if the disease comes back.

Lenalidomide is a more potent form of thalidomide. It has fewer side effects but can cause tingling or numbness, fatigue, rashes, and more serious conditions, such as shortness of breath or seizures. Lenalidomide is the most common immune-modifying drug. It is included in most initial treatments and also for maintenance.

Pomalidomide (Pomalyst®) is the most recent immune-modifying drug approved for people with multiple myeloma. It can be effective when lenalidomide and other drugs stop working.

Researchers believe that thalidomide, lenalidomide, and pomalidomide help the body’s immune system cause the death of cancer cells and stop myeloma cells from growing and living in bone marrow. Our doctors use a combination of lenalidomide and low-dose dexamethasone to treat many people who are newly diagnosed and who have limited organ damage.

Chemotherapy

Chemotherapy is a drug or combination of drugs that spreads throughout the body to kill cancer cells and control their growth. You can receive chemotherapy by mouth or intravenously.

At MSK, your care team will include medical oncologists who specialize in planning your chemotherapy for the disease. Our doctors understand the subtleties of chemotherapy regimens. They will personalize your treatment to optimize its strength and minimize side effects.

The most common treatment regimens for multiple myeloma include dexamethasone along with chemotherapy drugs or with other types of medications. The chemotherapy drugs may include melphalan (Alkeran®), doxorubicin (Adriamycin ®, Rubex®), or cyclophosphamide (Cytoxan®, Neosar®).