Practical Considerations for Reducing Risk and Providing Supportive Care

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Insights on supportive care measures to minimize or counter common adverse effects for patients with R/R MM taking selinexor-based therapies

Dr. Joshua Richter: You mentioned those terms of heme tox, that the drug really does have a predilection towards the megakaryocytes and thrombocytopenia is there. And one of the things that we saw in STORM when we gave the drug twice a week is we couldn't overcome this with TPO mimetics, but when we give it once a week, we can. The one thing, though, is when we use TPO mimetics, you have to ramp up the dose really fast. So if you look at the end plate, like package insert, they'll say start at one mic per kilo and then a week later go to two and a week later go to three, and you go up one at a time to a max of ten. And a lot of these patients we go like two, five, ten, or five, ten, we ramp it up rather quickly. Because if you use selinexor in later lines, you could have more thrombocytopenia. We see less of that severe thrombocytopenia in the early lines. But those are my two little tips and tricks. Don’t know your thoughts on the matter.

Dr. Peter Forsberg: No, its interesting I also use rolapitant. I think it's a good agent. I may flip-flop and use olanzapine as my second anti-emetic, but I always start with at least two essentially, and with a 5HD3 as part of the initial round dosing, usually. And then if patients have done well, we can always scale back, it's easier to reduce something, and I try to start with a buffed up anti-emetic protocol. I – really low-threshold to have dieticians involved for counseling, often we try to do that if we can coordinate with initiation, just to make sure that they're prepared for some maybe changes in appetite. And also that we're getting fluids, including something maybe with some salt in it, as part of reducing the risk for the hyponatremia. And then I agree this is one of the scenarios where I'm most likely to grab onto a thrombopoietin mimetic as part of our supportive approach, that it's something that I think – considering GCSF certainly, I don't hesitate to use that as part of our supportive approach. But also to think about a TPO mimetic to try to help to deal with some of the hematologic profile that's specific to this agent. And certainly monitoring most closely during cycle one. Weekly visits, weekly counts, and more common metabolic profile during cycle one, and then can space out from there, especially if they're on something like the all-oral combination with Pomalyst. So I think we've covered some of our supportive care approach, do you think that a better understanding for that supportive care has impacted your utilization of selinexor or your practice profile?

Dr. Joshua Richter: 100%. I saw a patient literally early on this week. Again, these are real-life cases, where a patient had received the drug locally, without all of this stuff that you and I use on our day-to-day clinic. He took one dose of it, said I'm never taking this drug again. And I said, you’re responding, why not? He said, I refuse. And then we went onto another regimen that failed and I said, listen, we're running out of options. Let's do it the way that that you and I, Peter, have already talked about. Let's do it the way that we know works and lower the dose. Gave him Varubi, olanzapine. I saw him this week. He's a cycle-and-a-half into it, has not had any of these problems, and it's a therapy for someone who's penta-refractory where nothing else is working. So, yeah, I think the notion of being proactive here is really a game-changer. And for those that you can keep on it, that they can do pretty well.

Dr. Peter Forsberg: Yeah. And it's certainly an agent you want to have in your toolbox. I think the good thing about myeloma is our toolbox is broader, and that's where – we're able to draw from that. But we're still certainly not in a place where we want to not have comfort and accessibility of those options that can help to fill in some of the gaps with other therapies that we have access to, and just be able to bring really robust different options into the mix for folks when we need them.

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