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Step-Up Dosing for Multiple Myeloma Treatment in the Outpatient Setting
Noa Biran, MD, John Theurer Cancer Center, Hackensack, New Jersey, explains the process of step-up dosing while transferring patients with multiple myeloma to an outpatient setting.
The step-up dosing in the hospital is administered for the majority of the bispecific T-cell engagers; there's 3 total doses. For talquetamab, there's 4 total doses and they can be administered anywhere from 48 hours apart or more, but the minimum is 48 hours apart.
Often, we do day 1, 3, and 5. If the patient experiences [cytokine release syndrome] CRS or [immune effector cell-associated neurotoxicity syndrome] ICANS or any toxicity, then all those symptoms have to be resolved before you receive the next dose. Once the patient achieves the therapeutic dose, they have to be monitored for at least 24 hours in the hospital to ensure no toxicity.
And if the patient is discharged, then they can come either for weekly dosing in the outpatient [setting] or biweekly dosing, depending on which drug it is. In general, the risk of [CRS] and ICANS diminishes significantly in the outpatient setting.
What we worry about more is preventing infections because these patients become lymphodepleted and [develop] hypogammaglobulinemia. So, we have to be proactive about [intravenous immunoglobulin] IVIG, prophylactic antiviral and anti- [Pneumocystis jiroveci pneumonia] PJP prophylaxis and have a low threshold for starting antibiotics at any sign of a bacterial infection.
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