Have a Cocktail: Using Multiple Drugs to Treat Myeloma

Cocktails of three, four or even five drugs of various classes are turning myeloma into a chronic condition.
Ron Malinowski, a retired engineer living outside Ann Arbor, Michigan, was diagnosed with multiple myeloma in December 2014. He underwent a stem cell transplant in August 2015, followed by a year of chemotherapy.

Still, the myeloma came back. In a two-week period in early September of this year, Malinowski’s myeloma seemed to explode.

“It just went crazy in one week,” Malinowski, 70, remembers. “It spread from my bones to my whole torso: my lungs, my intestines. We were afraid I wasn’t going to make it much longer.”

After trying just about everything else, Malinowski’s medical team put him on a “triplet” combination colloquially called “Elo-Rev-Dex.” One of the drugs in the combination, Empliciti (elotuzumab), was not yet approved for the treatment of myeloma when Malinowski was diagnosed; now, it’s approved as part of this combination, which includes: Empliciti, a monoclonal antibody, to enlist his own immune system to fight the cancer. An immune modulator, Revlimid (lenalidomide), that targets cancerous plasma cells while also boosting the immune system. Dexamethasone, a corticosteroid, which reduces cancer-induced inflammation and can kill some cancer cells.

Each of those agents works in a slightly different way to fight cancer; side effects can include blood clots, fatigue and lowered red and white blood cell counts. The combination worked for Malinowski. Within a month and a half, his blood tests indicated that he was experiencing a major remission.

“It’s ‘minimal residual disease’ now,” Malinowski says. “It’s amazing to be part of this cutting-edge change.”

A multiple myeloma diagnosis used to mean that a patient could only expect to survive three to five years. Today, that landscape has changed so much that it’s almost unrecognizable. Multiple myeloma remains incurable, but it is becoming more manageable. Doctors are beginning to talk of it as a “chronic disease.” Some are becoming optimistic enough to say that a cure might be possible within a decade.

“Twenty years ago, when I was in training, multiple myeloma was awful,” says Craig Cole, M.D., Malinowski’s doctor and an assistant professor in the Division of Hematology/Oncology at the University of Michigan. “Everyone was dying in three years or less. Now, people are surviving and surviving. And with the new drugs, they’re surviving with quality of life.” Progress has been steady over the last decade, with eight new drugs making their way into the myeloma toolbox between 2004 and 2014.

Then, in 2015, four additional treatments were approved by the FDA and one was given a new indication, demonstrating that progress had made a quantum leap. Among the treatments approved last year is the Elo-Rev-Dex triplet. Empliciti hones in on a protein called SLAMF7, which sits on the surface of myeloma cells, and then stimulates the body’s immune system to attack those cells. The recently approved Darzalex (daratumumab) is also a monoclonal antibody, but it targets a different protein on the surface of myeloma cells, CD38.

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