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Chemotherapy and Drug Therapy

The main treatment for active myeloma is systemic drug therapy (meaning the drugs travel through the bloodstream to kill malignant cells). The initial therapy, or “induction therapy,” for myeloma usually includes a combination of targeted agents and/or standard chemotherapy. This therapy is often followed by stem cell transplantation in eligible patients.

Induction therapy, given before the transplant, has several goals:

  • Achieve rapid disease control, potentially reversing organ dysfunction
  • Induce high response rates with as few side effects as possible, so that patients can proceed to the next phase of treatment
  • Allow adequate stem cell collection (harvesting) for transplant

For transplant candidates, drug treatment begins with an induction phase consisting of a combination of agents that do not cause marrow damage, for example:

  • Bortezomib (Velcade®), lenalidomide (Revlimid®) and dexamethasone (a combination known as VRD)
  • Bortezomib, cyclophosphamide (Cytoxan®) and dexamethasone (a combination known as VCD or CyBorD)
  • Or other combinations, such as the addition of daratumumab (Darzalex®)

Note that long-term treatment with lenalidomide may decrease stem cell production. So, for transplant candidates, stem cell collection is often performed after three to six cycles, once a good treatment response has been achieved.

Drugs Used for Myeloma Treatment

Drugs regularly used to treat myeloma either alone or in combination with other drugs include

  • Proteasome Inhibitors
    • Bortezomib (Velcade®)
    • Carfilzomib (Kyprolis®)
    • Ixazomib (Ninlaro®)
  • Immunomodulatory Drugs (IMiDs)
    • Lenalidomide (Revlimid®)
    • Pomalidomide (Pomalyst®)
    • Thalidomide (Thalomid®)
  • Monoclonal Antibodies
    • Elotuzumab (Empliciti®)
    • Daratumumab (Darzalex®)
    • Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)
    • Isatuximab-irfc (Sarclisa®)
    • Denosumab (Xgeva®)
  • Alkylating Agents (DNA-Damaging Drugs)
    • Melphalan hydrochloride (Evomela®)
    • Carmustine (BicNU®)
    • Cyclophosphamide (Cytoxan®)
    • Melphalan (Alkeran®)
  • Selective Inhibitor of Nuclear Export (SINE)
    • Selinexor (Xpovio®)
  • Chimeric Antigen Receptor (CAR) T-Cell Therapy
    • Idecabtagene vicleucel (Abecma®)
    • Ciltacabtagene autoleucel (Carvykti™)
  • Corticosteroids
    • Dexamethasone
    • Prednisone
  • Antitumor Antibiotics
    • Liposomal doxorubicin (Doxil®)
    • Doxorubicin (Adriamycin®)
  • Antimetabolites
    • Cytarabine (cytosine arabinoside, Ara-C, Cytosar-U®)
  • Bispecific B-cell maturation antigen (BCMA)
    • Teclistamab-cqyv (Tecvayli™)

Drugs used to fight myeloma-related bone disease

  • Bisphosphonates
    • Pamidronate (Aredia®)
    • Zoledronic acid (Zometa®)
  • Bone-modifying agent 
    • Denosumab (Xgeva®)

For information about these drugs, visit Drug Listings.

Oral Therapy and Adherence 

Treatment methods for myeloma patients have changed a lot over the last several years. Today, some of the drugs used to treat myeloma are taken by mouth, which is called “oral treatment” or “oral therapy." “Adherence” means staying on a set plan or regimen, taking the medication as prescribed—on the right day and at the right time and reporting side effects to your doctor. Poor adherence to a prescribed oral drug regimen can result in the following: drug resistance; poor response to therapy; disease progression; increased doctor visits, laboratory tests and hospitalizations; and even death.

Download or order the following free LLS resources:

Maintenance Therapy

Maintenance therapy is the continued use of therapy to maintain the response obtained with induction therapy or stem cell transplantation. During maintenance therapy, medications are given at lower doses or with less frequency to keep the successful results of prior treatment going.

Lenalidomide (Revlimid®) is the preferred agent for post-transplant maintenance, based on the results of several clinical trials. It does not produce the neurotoxicity of other immunomodulatory drugs, such as thalidomide. However, lenalidomide appears to increase the risk for developing a secondary cancer during maintenance therapy, especially after transplantation or after therapy with a regimen that contains melphalan. More information is needed about the effects of maintenance therapy on overall survival, as well as second cancer risk.

Maintenance therapy with bortezomib (Velcade®) or ixazomib (Ninlaro®) is recommended for patients with certain cytogenetic abnormalities.

Maintenance therapy is intended to be continued over the long term. If, or when, there are signs and/or symptoms indicating disease progression, you and your doctor will discuss additional treatment. 

For information about other drugs and drug combinations used for myeloma treatment, access the free booklet, Myeloma.

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