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IMS 2026 | Deciding on Isa-VRd over a triplet-only approach in TI NDMM
Xavier Leleu, MD, PhD, Poitiers University Hospital, Poitiers, France, discusses the decision to use a quadruplet regimen, such as isatuximab in combination with bortezomib, lenalidomide and dexamethasone (Isa-VRd), over a triplet approach in transplant-ineligible newly diagnosed multiple myeloma (TI NDMM). Prof. Leleu believes that the benefit-risk balance favors the quadruplet, as treatment can be adapted to improve the safety profile, but survival cannot be rescued if a less intensive regimen is used initially. This interview took place at the 23rd International Myeloma Society (IMS) Annual Meeting in Glasgow, UK.
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Transcript
When you decide on treatment, first of all, you decide on survival. And so in that regard, if you think the patient is quadruplet fit, given that the survival of the quadruplet is now demonstrated so much better than the triplet, at least at ten years, our data seems to say so, then I would say use a quadruplet, not the triplet-based regimen. No, I acknowledge that when you give the quadruplet with dexamethasone, bortezomib, you will bring a certain degree of side effects...
When you decide on treatment, first of all, you decide on survival. And so in that regard, if you think the patient is quadruplet fit, given that the survival of the quadruplet is now demonstrated so much better than the triplet, at least at ten years, our data seems to say so, then I would say use a quadruplet, not the triplet-based regimen. No, I acknowledge that when you give the quadruplet with dexamethasone, bortezomib, you will bring a certain degree of side effects. But I still believe that the benefit-risk balance is in favor of the benefit. Because you can always adapt your treatment. But you cannot change the survival of the patients. If you initially have a patient that you’re going to start at three drugs and later on you’ll increase, you’ll escalate to four drugs. I haven’t seen that. And I don’t think many physicians would do that. So you cannot, I don’t think you can rescue the survival, but you can always adapt your treatment to improve the safety profile. So I think the balance benefits risk is in favor of the quadruplet. And I think you can always start four and decrease. Not too many patients will start three or two drugs and increase. So yes, I wish carfilzomib would be available. I wish in Europe carfilzomib would be approved upfront. I wish we would have a proteasome inhibitor, very ultra-safe, no neurotoxicity, no fatigue, no diarrhea, nothing to bother the patients and their healthcare professionals. I wish, but the reality is that it’s not the case. But again, I still believe that we know how to adapt bortezomib. We’ve been using bortezomib since 2005, 2008, for about 10, 15 years, 20 years at most, and we know how to do it right now.
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