Bispecifics in Relapsed/Refractory Multiple Myeloma: Adverse Event Management


Focused discussion on mitigating and managing the adverse event profiles of bispecifics in relapsed/refractory multiple myeloma.


Krina K. Patel, MD, MSc: What are the other reasons you can think of? You mentioned this already and I’m going to ask you because your resources are a little bit harder to get. We’re all in the main campus and I can just call my colleagues up. What are other reasons that patients might need to be hospitalized because of bispecifics, besides just CRS [cytokine release syndrome] and ICANS [immune effector cell–associated neurotoxicity syndrome]?

Tejo N. Musunuru, MD: I’d say infections. The biggest risk is infections. We should be on top of every patient, even if they’re not under our care. We’re all consultants at a different hospital so we just have to give them very specific guidelines as to what antibiotics to use. Sometimes they call the infectious disease doctors and sometimes we have this little tiff about what the standard guidelines are and what is best because most other hospitals are using standard guidelines not for neutropenic patients, so our patients are a little different. Sometimes I’m trying to not argue with you or fight with you. It’s just that this is our experience so please do this.

Krina K. Patel, MD, MSc: I was going to ask you what the typical infections are that you look for in a patient who’s gotten CAR [chimeric antigen receptor] T or bispecific, for example, for neutropenic fever.

Sairah Ahmed, MD: I think that’s a really good point because if you have a patient that goes into the community with a fever without necessarily having the experience of someone who is post–CAR T or postbispecific, because at this point they’re postbispecific, they have had several lines of therapy so they are very immunosuppressed and so we see a lot of atypical viruses. So you can have CMV [cytomegalovirus] reactivation, you can have EBV [Epstein-Barr virus] reactivation, and HHV-6 [human herpesvirus 6] is another one. You can also have fungal infections or atypical bacterial infections. I think that’s where our infectious disease colleagues are a huge bonus in the main campus because they come at these patients with the experience of, “We’re going to treat the horses but we’re also going to look for the zebras.” Often, we find these patients who do have CMV reactivation with very high CMV viral loads and so we’re treating them with multiple drugs that often you would not use in other hospitals or in the outpatient setting. I think as we start to move forward and we sequence these different agents, we’re probably going to see different patterns of infection emerge and it’s going to be different for myeloma compared to lymphoma, the T-cell dysfunction vs the B-cell aplasia. That’s where I think guidelines coming from larger groups such as ASTCT [the American Society for Transplantation and Cellular Therapy] or the myeloma groups and lymphoma groups who are going to be using these drugs, have trial experience with some long-term follow-up can help create these guidelines for monitoring.

Tejo N. Musunuru, MD: That brings up a very good point about some of the hospitals and how they’re very worried about the reimbursements because here, our infectious disease colleagues know exactly what to do. So the other hospitals, 1 thing they’ve tried to do is they like to go up the ladder. “Let’s see if this doesn’t work because I don’t know if you get paid for that based on the insurance giving it inpatient,” and those kinds of things. I’ve noticed that in a lot more in the hospitals outside [The University of Texas) MD Anderson [Cancer Center].

Krina K. Patel, MD, MSc: It’s a different setup completely and it does affect the entire setup of your hospital. Oncology makes just this much of your patient population vs for us, it’s everything, so I completely agree. The logistics are a little bit harder for the inpatient piece but hopefully, we’re going to learn how to do this all outpatient. The earlier it goes, there’ll be less infections, hopefully. But I think still all of these things are really, really important as this is being rolled out.

Melody R. Becnel, MD: I think as we’re kind of learning with all these new agents and kind of getting data long term, we’ll know which medications we actually need to have patients on for prophylaxis, which is maybe something were not already doing and we’ll learn that over time so time will tell.

Krina K. Patel, MD, MSc: Perfect.

Transcript edited for clarity.

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