BORTDEXALENA+DARA; LENA+DARA(MNT)

Lenalidomide may only be prescribed and dispensed by physicians and pharmacists registered with a controlled distribution program. Patients must also be registered and meet all conditions of the program.

¹ In elderly patients, the dexamethasone dose should be reduced (i.e. to 20 mg once weekly).

² May increase lenalidomide to 15 mg after 3 cycles

REPEAT EVERY 28 DAYS

For 4 induction cycles before transplant and 2 consolidation cycles post-transplant

LENA+DARA(MNT): Repeat every 28 days until disease progression or unacceptable toxicity, or up to 2 years total

• Also refer to CCO Antiemetic Recommendations.
   

Screen for hepatitis B virus in all cancer patients starting systemic treatment. Refer to the hepatitis B virus screening and management guideline.
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Daratumumab pre-medications (prophylaxis for infusion reaction):

To be given at least 1 hour prior to daratumumab infusion:

• Dexamethasone 20 mg IV/PO^*
• Oral antipyretic (e.g. acetaminophen 650-1000 mg)
• H1-receptor antagonist IV/PO (e.g. diphenhydramine 25-50 mg or equivalent)
• Famotidine 20 mg IV (or equivalent)
• Montelukast 10 mg PO^**

*_{Administer IV prior to the first infusion; Oral administration may be considered prior to subsequent infusions. Dexamethasone on the day of infusion may be given as part of pre-/post-medications for daratumumab; 20 mg IV/PO on the day of daratumumab infusion and 20 mg PO on the day after infusion. For patients receiving reduced dose dexamethasone 20 mg weekly, the entire 20 mg dose has been given prior to the daratumumab infusion in some clinical trials.}

**_{The addition of montelukast given prior to the first infusion numerically reduced the incidence of respiratory IRs in the study by Nooka et al.}

Post-daratumumab infusion medications (prevention of delayed reactions):

• Dexamethasone 20 mg PO on the day after daratumumab infusion* 
• Consider bronchodilators (e.g. short and long acting) and inhaled corticosteroids if chronic obstructive pulmonary disorder^&****

*_{Dexamethasone on the day of infusion may be given as part of pre-/post-medications for daratumumab; 20 mg IV/PO on the day of daratumumab infusion and 20 mg PO on the day after infusion. For patients receiving reduced dose dexamethasone 20 mg weekly, the entire 20 mg dose has been given prior to the daratumumab infusion in some clinical trials.}

^&Consider adding an H1-receptor antagonist if the patient is at higher risk of respiratory complications.

***These may be discontinued after the 4th infusion if no major IRs occurred.
 

Other Supportive Care:

• HBV screening should be performed in all patients prior to starting daratumumab.

• Daratumumab can interfere with cross-matching for blood transfusions; type and screen and RBC genotyping tests should be done before starting this drug.

• Antiviral prophylaxis for herpes zoster is recommended.

• Patients at risk of tumour lysis syndrome should have appropriate prophylaxis and be monitored closely.

• For lenalidomide, prophylaxis for venous thromboembolism is recommended in patients at risk (e.g. low dose aspirin 81-100 mg PO daily or enoxaparin 40 mg SC daily).

• Careful consideration and monitoring must be taken with erythropoietin stimulating agents (ESAs), since the concomitant use of ESAs with lenalidomide may potentiate the risk of thrombosis.  RBC or platelet transfusions with lenalidomide dose reductions/interruptions may be appropriate in severe / symptomatic anemia or thrombocytopenia.

• Consider GCSF as secondary prophylaxis.

• Optimal control of thyroid function is recommended prior to starting lenalidomide treatment.

Lenalidomide, Dexamethasone: Outpatient prescription for home administration

Bortezomib, daratumumab and lenalidomide drug monographs. Ontario Health (Cancer Care Ontario).

Voorhees PM, Kaufman JL, Laubach J, et al. Daratumumab, lenalidomide, bortezomib, and dexamethasone for transplant-eligible newly diagnosed multiple myeloma: the GRIFFIN trial. Blood 2020 Aug 20;136(8):936-45.