Monoclonal Antibodies for Myeloma: Make It Easy!

The introduction of the monoclonal antibodies daratumumab (directed against CD38) and elotuzumab (directed against SLAMF7) represents the latest wave of therapeutic advances in the treatment of multiple myeloma and other plasma cell disorders.1-7 The efficacy that has been observed with monoclonal antibodies, especially in combination with other myeloma therapies, suggests that this class of drugs will play a major role in the management of these disorders for the next decade and beyond. Monoclonal antibodies are no strangers to the hematology–oncology community, and most oncologists are familiar with managing the typical adverse events associated with this class of drugs. However, there will definitely be a learning curve associated with the use of these agents in the treatment of plasma cell disorders. Most of the experience has been limited to the treatment of multiple myeloma, but early experience with other plasma cell disorders points toward these agents playing a significant role in the treatment of all plasma cell disorders. Although both daratumumab and elotuzumab are associated with the typical infusion reaction symptoms, daratumumab has an added feature of respiratory symptoms thought to be related to the expression of its target (CD38) on the respiratory epithelium. Nooka et al8 have nicely summarized the available data on the efficacy and use of these two monoclonal antibodies for treatment of multiple myeloma. They outlined their own experience with the use of daratumumab and the frequency of infusion-related reactions observed. Specifically, they described how they have adapted their management of reactions with increasing experience with the use of these drugs. It is important that these infusion reactions are prevented to the extent possible to increase the probability of patients continuing on therapy and thus improving their outcomes. The allergic reactions, especially the respiratory symptoms, can be quite challenging for the typical elderly patient with multiple myeloma who may have pre-existing respiratory conditions. The authors outlined the use of montelukast in these patients and how its use seems to have decreased the frequency and severity of the respiratory symptoms. Although the changes do not seem to be statistically significant, the trend is clear and thus montelukast should be considered a routine preinfusion prophylaxis in patients receiving daratumumab. The authors have provided a clear set of recommendations for managing infusion-related reactions and the optimal use of pre- and postinfusion prophylactic medications.