Multiple Myeloma MCQ — NEET PG Practice Question | NEETPGAI
Multiple Myeloma
hard
microscope Pathology
A 58-year-old woman with relapsed multiple myeloma (after 18 months of remission on VTD induction and ASCT) presents with rising M-spike and bone pain. She has normal renal function and no neuropathy. Which drug is the preferred first-line option for relapsed/refractory multiple myeloma (RRMM) in this patient?
A. Lenalidomide + dexamethasone
B. Bortezomib + dexamethasone
C. Carfilzomib + dexamethasone
D. Pomalidomide + dexamethasone
Explanation
First-Line Treatment of Relapsed/Refractory Multiple Myeloma (RRMM)
Key Point
Lenalidomide + dexamethasone is the preferred first-line regimen for relapsed multiple myeloma (MM) in patients who have not previously received lenalidomide and have adequate renal function.
Standard Approach to RRMM
The choice of salvage therapy depends on:
1.
Prior therapy exposure: What drugs were used in induction and maintenance?
2.
Time to relapse: Early relapse (<12 months) suggests aggressive biology
3.
Organ function: Renal function, neuropathy status
4.
Patient fitness: Ability to tolerate combination therapy
First-Line RRMM Regimens
Table
Scenario
Preferred Regimen
Rationale
Prior PI, no prior IMiD
Lenalidomide + Dex
IMiD-naïve; excellent response rates (60–70% ≥PR)
Prior IMiD, no prior PI
Bortezomib + Dex or Carfilzomib + Dex
PI-naïve; rapid response
Prior both PI and IMiD
Pomalidomide + Dex
Pomalidomide active in lenalidomide-refractory disease
Early relapse (<12 mo)
Carfilzomib + Dex
Faster kinetics; higher response rates
High-YieldNEET PG
In this patient:
Prior therapy: VTD + ASCT (bortezomib-based, so PI-exposed)
No prior lenalidomide exposure
Normal renal function (no contraindication to IMiDs)
No neuropathy (can safely re-challenge bortezomib if needed)
Time to relapse: 18 months (intermediate; not ultra-early)
Therefore: Lenalidomide + dexamethasone is optimal — IMiD-naïve status, good renal function, and proven efficacy in PI-pretreated patients.
Mechanism of Lenalidomide
Lenalidomide (immunomodulatory drug, IMiD):
Cereblon (CRBN) binding → selective degradation of IKZF1 and IKZF3
Enhanced T-cell proliferation and IL-2/TNF-α production
Direct anti-angiogenic effects
Synergistic with dexamethasone
Why Not Other Options?
Pomalidomide + Dex:
Reserved for lenalidomide-refractory disease (progression on lenalidomide)
This patient is lenalidomide-naïve; pomalidomide is more toxic and should not be used first-line
Higher rates of infection and cytopenias
Bortezomib + Dex:
Patient already received bortezomib in induction (VTD)
While re-challenge is possible, lenalidomide is preferred as a switch strategy in PI-pretreated patients
Risk of cumulative neuropathy if bortezomib is re-used
Carfilzomib + Dex:
Second-generation PI; excellent for early relapse (<12 months)
This patient has intermediate time to relapse (18 months), not ultra-early
Carfilzomib is more expensive and reserved for PI-refractory or very aggressive disease
Not first-line in PI-pretreated, IMiD-naïve patients
Clinical Pearl
The principle of RRMM management is "switch class" when possible — if the patient received a PI in induction, use an IMiD in relapse; if they received an IMiD, use a PI. This maximizes response rates and delays resistance.
Mnemonic
RRMM Strategy = Switch Class
Prior PI (bortezomib) → Use IMiD (lenalidomide)
Prior IMiD → Use PI (bortezomib or carfilzomib)
Prior both → Use pomalidomide (most potent IMiD)
Evidence Base
MM-009 / MM-010 trials: Lenalidomide + dexamethasone vs. dexamethasone alone in relapsed MM → superior PFS and OS with lenalidomide
ASPIRE trial: Lenalidomide + bortezomib + dexamethasone (RVD) superior to bortezomib + dexamethasone in relapsed MM
ENDEAVOR trial: Carfilzomib superior to bortezomib in relapsed MM, but lenalidomide is still preferred first-line in IMiD-naïve patients
Harrison 21e Ch 191
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