Use, Regimen, Cost, and Side Effects

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The American Cancer Society Estimates that doctors will diagnose multiple myeloma in 34,470 people in the United States in 2022. Multiple myeloma, or myeloma, is a blood cancer that develops in plasma cells. These specialized white blood cells make antibodies to signal for your immune system to attack foreign substances.

The VRd regimen, also written as RVd, is a three-drug therapy doctors often use as the first treatment for myeloma. It tends to be well tolerated and is associated with high remission rates. The three drugs in this regimen are:

  • bortezomib (Velcade)
  • lenalidomide (Revlimid)
  • dexamethasone

According to the International Myeloma Foundation, more than 90% of people with myeloma respond well to initial therapy. Even so, doctors don’t usually consider it a curable disease. The goal of treatment is often to decrease the number of cancerous cells in your bone marrow and to manage symptoms.

In this article, we look at when doctors may recommend VRd, its potential side effects, and its effectiveness.

VRd is the preferred initial treatment for people with myeloma who are candidates for a procedure called an autologous stem cell transplant.

This procedure involves removing blood-producing stem cells from your bone marrow before undergoing high doses of chemotherapy. The cells are replaced in your bone marrow once chemotherapy is complete.

According to the International Myeloma Foundation, doctors generally recommend these stem cell transplants for people under the age of 65 with no severe health issues. Adults ages 65 and over in excellent health may also be eligible in some cases.

VRd is also one of the two main initial treatments used in people who aren’t eligible for an autologous stem cell transplant. The other main option is called DRd, which uses:

  • daratumumab
  • lenalidomide
  • dexamethasone

The VRd regimen is a combination of three medications. You take the medications on a 21-day cycle. A doctor will adjust the doses of these medications based on how you respond and the severity of your side effects.

Here’s a look at what a possible schedule looks like:

In a 21-day cycle, you’ll receive treatment for the first 14 days and then rest for the next 7 days.

Doctors generally recommend that people receiving VRd also receive anticoagulants to prevent blood clotting and antiviral therapy to prevent shingles. Shingles is a reactivation of the varicella-zoster virus that causes chickenpox.

The three drugs in the VRd regimen attack myeloma cells in different ways:

  • Bortezomib: Bortezomib is a proteasome inhibitor. It targets myeloma cells in several ways. It can disrupt their cell cycle and induce a form of cellular death called apoptosis.
  • Lenalidomide: Lenalidomide is an immunomodulatory agent. It stimulates your immune system to destroy myeloma cells.
  • Dexamethasone: Dexamethasone is a steroid. It helps to reduce pain and inflammation and manage the side effects of other medications. High amounts of steroids can also help destroy myeloma cells.

VRd is generally well tolerated but can cause many side effects. Side effects that affect more than 10% of people include:

  • fatigue: 16%
  • neuropathy: 23%
  • low hemoglobin, the oxygen-carrying part of your red blood cells: 13%
  • low white blood cell count:
  • low level of platelets, the blood cells that cause clotting: 18%

Bortezomib (Velcade)

According to the Velcade website, side effects of bortezomib can include:

Lenalidomide (Revlimid)

According to the Revlimid website, common side effects of lenalidomide include:

Dexamethasone

Common side effects include:

VRd is currently the standard treatment for people with newly diagnosed myeloma. Research suggests that the VRd regimen is generally an effective and well tolerated initial treatment. A 2017 European study with 700 participants found a 4-year survival overall rate of more than 80% with or without an autologous stem cell transplant.

In a 2022 studyresearchers found that among 187 people with myeloma who received VRd and an autologous stem cell transplant, the average overall survival was 101.7 months (8.5 years).

Researchers followed up with participants an average of 63.2 months after treatment. At follow-up, 57.2% of people reached complete remission and 87.1% had a very good partial response.

In another 2022 studyresearchers compared to the VRd regimen to another regimen called VCD, which is made up of:

  • bortezomib
  • cyclophosphamide
  • dexamethasone

The researchers found that the median progression-free survival (PFS) was 44.6 months in people who received VRd versus 34.1 months in the VCD group. Median PFS is the length of time half of people survived with no progression in their cancer.

Myeloma treatment can be very expensive. Your insurance may cover most or some of the cost, but it’s important to check your coverage before starting VRd treatment.

A 2016 study estimated that VRd costs more than $150,000 per year. A 2021 study found the average overall cost of VRd was $385,434. If you don’t respond to initial treatment, you may have additional costs.

Medicare covers many cancer expenses:

  • Part A covers hospital care.
  • Part B covers outpatient expenses such as doctor visits, chemotherapy drugs administered in an outpatient clinic or doctor’s office, and diagnostic tests.
  • Part D covers prescription drugs.

Medicare Part B covers chemotherapy drugs such as bortezomib, but you generally have to pay 20% out of pocket.

People with active myeloma often receive a combination of two to three Medications. Doctors often use the VRd regimen to treat newly diagnosed myeloma.

Doctors may also perform an autologous stem cell transplant along with VRd in eligible people.

If the initial treatment isn’t effective or you’re not eligible for a stem cell transplant, doctors may recommend a different combination of medications.

You may receive bisphosphonates at the same time as chemotherapy to target bone problems such as osteoporosis and fractures. You may receive radiation therapy if particular areas of your bone are causing symptoms.

You may also receive supportive treatment such as antibiotics and blood transfusions.

Doctors sometimes recommend chimeric antigen receptor (CAR) T-cell therapy if other treatments have failed, but it can cause serious side effects.

This therapy involves extracting a type of white blood cell called T cells from your blood. Scientists alter the blood cells in a laboratory so that they attack cancer cells, and then reinsert the altered cells into your blood.

The VRd regimen is often the initial treatment for people with myeloma. If you’re eligible for a stem cell transplant, a doctor may combine VRd with your transplant. If VRd fails as an initial treatment, a doctor will likely recommend another combination of medications.

Doctors use many different combinations of drugs to treat myeloma. Researchers are constantly examining whether new combinations are more effective than the current standard treatments.

A doctor can help you figure out if VRd is the best option for you or whether you may benefit from a different treatment.

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