## First-Line Induction Therapy in Transplant-Eligible Multiple Myeloma **Key Point:** VRd (bortezomib, lenalidomide, dexamethasone) is the preferred induction regimen for transplant-eligible patients with newly diagnosed multiple myeloma, as recommended by NCCN and ASCO guidelines. ### Rationale for VRd 1. **Proteasome inhibitor + IMiD synergy**: Bortezomib (proteasome inhibitor) and lenalidomide (immunomodulatory drug) target complementary pathways in myeloma cells. 2. **Superior response rates**: VRd achieves complete remission or very good partial remission (VGPR) in >80% of transplant-eligible patients. 3. **Cytoreduction before ASCT**: Reduces tumor burden pre-transplant, improving post-transplant outcomes. 4. **Manageable toxicity**: Reversible peripheral neuropathy from bortezomib is dose-limiting but controllable with subcutaneous administration. ### Alternative Induction Regimens | Regimen | Patient Population | Rationale | |---------|-------------------|----------| | VRd | Transplant-eligible, standard risk | First-line; superior efficacy | | VTd (bortezomib, thalidomide, dex) | Transplant-eligible, older age | Alternative if lenalidomide contraindicated | | KRd (carfilzomib, lenalidomide, dex) | Transplant-eligible | Alternative proteasome inhibitor | | MP (melphalan, prednisone) | Transplant-ineligible, elderly | Oral, well-tolerated but lower response | **High-Yield:** VRd is the standard of care induction for transplant-eligible MM patients because it combines rapid cytoreduction with acceptable toxicity and improves progression-free survival compared to older regimens. **Clinical Pearl:** Bortezomib is typically given subcutaneously (not IV) in modern practice to reduce peripheral neuropathy risk while maintaining efficacy. [cite:Harrison 21e Ch 191]
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