It is the consensus of the Haematology Reference Committee that this protocol is not considered best practice in this patient population.
For many years, infusional vincristine, doxorubicin, dexamethasone (VAD) was used as pre-transplant induction therapy for patients who were candidates for AuSCT. However, disadvantages of VAD include the requirement for central venous lines, neurotoxicity, and a low CR rate of typically < 10%. VAD is therefore no longer considered the induction regimen of choice. Since the introduction of thalidomide, lenalidomide and bortezomib, many novel agent based combinations have been shown to induce a deeper response rate compared to VAD, and improve post-transplantation outcome.r Consequently, there has been a move towards incorporating novel agents into the induction regimen with the aim of increasing CR and VGPR rates post AuSCT. However, some induction regimens not containing novel therapeutic agents such as CID (cyclophosphamide, idarubicin, dexamethasone) and PCAB (doxorubicin, carmustine, cyclophosphamide, prednisolone) are also efficacious and are still currently utilised as first-line induction treatment in some Australian centres.
Drug |
Dose |
Route |
Day |
vinCRISTine |
1.6 mg |
IV |
1 |
DOXOrubicin |
36 mg/m2 |
IV |
1 |
Dexamethasone |
40 mg (cycle 1 and 3 - ODD cycles ) |
PO |
1 to 4, 9 to 12, and 17 to 20 |
Dexamethasone |
40 mg (cycle 2 and 4 - EVEN cycles) |
PO |
1 to 4 |
Frequency: 28 days
Cycles: 4 to 6 (Maximum of 12 cycles)
Notes:
- Use of a bone modifying agent (BMA) should be considered in all patients with symptomatic myeloma requiring treatment. For patients with newly diagnosed symptomatic myeloma, zoledronic acid, pamidronate or denosumab should be considered for monthly administration (adjust for kidney dysfunction where appropriate) for up to 2 years. A longer duration of therapy may be appropriate (MRC M IX trial).r
For more information, please see the following protocols:
- It is the consensus of the reference committee that a 20 mg/week starting dose of dexamethasone should be considered in patients > 75 years.r