My preferred induction treatment for an otherwise healthy 79-year-old patient is CRd (carfilzomib/lenalidomide/dexamethasone), more recently named as KRd. The next choice would be RVD.

Support for using KRd in this patient population comes from our recently published article in Haematologica that described subset analysis of patients who were 65 years or older, mostly not transplant eligible and who received KRd for an extended period of time. The outcomes were comparable to the general population. So I don’t see any good reason to avoid this active regimen that could control the disease for a longer period. Although the data for KRd in this population of patients come from single-arm trials, I believe they will hold up in randomized trials.

With RVD we don’t have a lot of data, but I’ve been administering this regimen to patients older than age 80 for more than 2 years and I can manage the toxicities without any problems. The complete response rate for patients who receive RVD is high.

For extremely frail elderly patients I would administer a 2-drug combination.

For a 79-year-old patient with standard-risk MM and normal renal function who is not eligible for transplant, I would recommend a lenalidomide/dexamethasone regimen. If the patient had more aggressive disease and was in good shape, I would administer a 3-drug combination, RVD, after a discussion with the patient.

For a 79-year-old patient in this scenario with standard-risk disease I would recommend lenalidomide with low-dose dexamethasone.

For an otherwise healthy 79-year-old patient who has standard-risk disease and normal renal function and is transplant ineligible, I would administer lenalidomide and dexamethasone.

In France the standard therapy for patients in this scenario is VMP or lenalidomide/low-dose dexamethasone. The available data demonstrate that the lenalidomide/low-dose dexamethasone regimen is superior to MPT. We don’t have any head-to-head comparison between VMP and lenalidomide/dexamethasone.

We perform a geriatric assessment for patients older than age 65. For patients who are fit I would use a 3-drug combination, which could be either VCD or VMP. I administer a 2-drug combination for patients who are frail or unfit. For example, I would administer Rd to a frail 80-year-old patient with comorbidities.

For a 79-year-old patient who has standard-risk disease and normal renal function, I would administer a modified RVD regimen, RVD lite.

I do not believe the data support recommending the most effective therapy only for patients at high risk. I believe, based on the evidence, that our approach should be to administer the best treatment for the patients at low risk also.

With RVD lite, factors like the patient’s comorbidities and the frailty index must be taken into account. Once you’ve adjusted the dose for these patients they will fare well. The older the patient, the more likely the need to modify the dose of these drugs. We administer lenalidomide at the 15-mg per day dose rather than the 25-mg per day dose. We also administer bortezomib weekly. In general this modified regimen is well tolerated.

My preferred induction regimen for a 79-year-old patient who is at standard risk and not transplant eligible is lenalidomide/dexamethasone.