Posted by Jeff Berk, BOLT International;
Another beautiful day in Paris. Unfortunately, all I got to see of it was the basement under the Louvre. Fortunately, Big Daddy is paying for me to be here at the International Myeloma Workshop, and it is really a great meeting. If knowledge was a drug, they are definitely administering dose-dense therapy. But 7:45am – 10:00pm is taking its toll on my martini consumption, and I can’t wait for Friday night. Today’s cactus is a Queen (Louie) of the Night. As I’ve said in prior posts, they usually only bloom at night. Unlike most queen of the nights, however, this one seems to bloom every night.
So a couple of weeks ago I posted a blog conveying some comments from BOLT’s Multiple Myeloma Thought Leader panel on the frequency of DVTs that they are seeing in their Revlimid (lenalidomide) and thalidomide patients. There have been a couple of interesting developments reported here that expand this discussion, and tonight I want to add my 2¢.
First, there was a nice poster by Heng Joo Ng, et.al. which reports that while the rate of VTE in Asian patients who are on IMiDs is lower than in Western patients, it still correlates with cumulative exposure. They found 17 cases of DVT due to lenalidomide or thalidomide therapy in a cohort of 234 myeloma patients (7.4%). The “accepted” rate in the West is 15%. Their final comment, “Patients on aspirin are not precluded from the risk of developing VTE”. This really caught my attention, and I’ll come back to this point in a minute.
So there has been over the past year a whole host of data showing that aspirin and placebo are equally effective in preventing DVTs. Translation: aspirin is worthless for preventing thromboembolic events (everywhere except places with a government bureaucracy that would call itself the ridiculously Orwellian name “NICE”).
So back to today’s session: Dr. Dimopoulos presented a consensus panel opinion on treating / managing a number of adverse events associated with bortezomib, lenalidomide, dexamethasone and thalidomide. To be clear, it was an excellent talk. Except… Here’s what the Consensus Panel came up with for the management and prevention of VTE. And I quote (with minor embellishment):
Thromboprophylaxis should be considered for patients treated with lenalidomide + Dex and should continue for the entire duration of treatment (okay, I’m good with this point).
Lenalidomide + Dex should be resumed in patients considered stable on anticoagulation therapy (can’t argue with that either).
Aspirin prophylaxis is appropriate for patients with standard VTE risk (we’re starting to diverge in our sentiment) and LMWH (low molecular weight heparin) is recommended for patients with higher risk of VTE (Huh?! Hey, rivaroxaban, dabigatran and apixaban guys – Are you going to stand for that?! I mean, isn’t enoxaparin so last century?)
LMWH should be continued for at least the four cycles of therapy; thereafter patients may be switched to aspirin prophylaxis. This is where he lost me. If a myeloma patient is at high enough thromboembolic risk to be on LMWH, how do you switch him back to placebo (er, aspirin) after four cycles of IMiD?
Okay, so to land this plane – This highlights one of the challenges in medicine today. In this example, for good cause, treaters who specialize in multiple myeloma are in the know regarding multiple myeloma. And the hospital pulmonologist and cardiologist who is going to treat DVT / PE (pulmonary embolism) are knowledgeable about direct thrombin inhibitors and FXa inhibitors. But the companies who are marketing / going to be marketing these antithrombotics are missing out on an opportunity to educate physicians (and their patients) who could be choosing better therapies.
Any myeloma treaters out there want to take an opposing view? Please post! – jb