Lenalidomide in multiple myeloma: current role and future directions

Cytomegalovirus Retinitis Associated with Lenalidomide Use for Multiple Myeloma in an Immunocompetent Patient

Purpose

The aim of this report is to present a case of cytomegalovirus (CMV) retinitis in an immunocompetent patient using lenalidomide.

Methods

Case report with fundus photography, spectral-domain optical coherence tomography, and fluorescein angiography imaging.

Results

A 55-year-old male with history of multiple myeloma treated with lenalidomide presented with blurriness and floaters in his right eye and was found to have vitreous biopsy-confirmed CMV retinitis. The patient was treated with pars plana vitrectomy, oral valganciclovir, and intravitreal foscarnet. More than one year later, the patient was doing well with visual acuity of 20/25 and no recurrence of retinitis.

Conclusion

This represents the second report of CMV retinitis associated with lenalidomide therapy. It suggests that even immunocompetent patients can be affected by CMV retinitis in the context of lenalidomide treatment. It is critical that patients being treated with lenalidomide receive prompt evaluation if they develop ophthalmic symptoms.

[Lenalidomide nephrotoxicity]

The introduction of lenalidomide into the therapeutic arsenal of hematologic malignancies has represented an important step forward in the management of multiple myeloma. However, its use is associated with several toxicities including kidney injury. The present review examines the drug's pharmacokinetics, discusses the main adverse renal effects that are associated with lenalidomide treatment, and makes recommendations for dosage adjustment in patients with underlying renal impairment.

A case of DRESS (drug reaction with eosinophilia and systemic symptoms) with acute interstitial nephritis secondary to lenalidomide

Acute kidney injury is commonly observed in patients with multiple myeloma and other plasma cell dyscrasias. The pathophysiologic causes, however, are varied. We report a case of a severe ‘drug reaction with eosinophilia and systemic symptoms’ syndrome associated with acute interstitial nephritis in a patient with multiple myeloma likely related to the administration of lenalidomide. This disease entity requires prompt recognition and cessation of the offending drug and often treatment with high-dose corticosteroids.

Current treatment strategies with lenalidomide in multiple myeloma and future perspectives

Lenalidomide is an immunomodulatory drug derived from thalidomide, developed to maximize its anti-inflammatory and antineoplastic properties while reducing toxicity. Lenalidomide administered orally at 25 mg/d on days 1-21 of 28-day cycles plus dexamethasone is indicated for the treatment of relapsed/refractory multiple myeloma patients, who received at least one prior therapy. In the pivotal MM-009 and MM-010 Phase III registration trials, lenalidomide-dexamethasone, when compared with placebo-dexamethasone, significantly improved response rate (60 vs 20%, respectively), time-to-progression and survival. The most common adverse events included hematologic toxicity and venous thromboembolism. The drug is currently being investigated for the treatment of newly diagnosed myeloma and, in association with chemotherapy drugs (cyclophosphamide and melphalan) or novel agents (bortezomib, carfilzomib and elotuzumab), for the development of highly active combination regimens.

Cytomegalovirus retinitis after treatment with lenalidomide for multiple myeloma

PURPOSE

To describe a case of cytomegalovirus retinitis in a patient after treatment with lenalidomide, a novel therapy in the treatment of multiple myeloma.

METHODS

Descriptive case report of a 67-year-old man on Lenalidomide maintenance therapy for multiple myeloma, who presented with unilateral painless blurring of vision because of retinitis.

RESULTS

Polymerase chain reaction of the vitreous sampling confirmed cytomegalovirus retinitis, although the patient's serum polymerase chain reaction was negative for cytomegalovirus. The patient was treated with ganciclovir with good effect.

CONCLUSION

Cytomegalovirus retinitis is rare in immunocompetent patients and not commonly reported in myeloma patients. Given the increasing use of novel therapies such as Lenalidomide, unusual infections such as cytomegalovirus retinitis should be considered in patients with visual symptoms, even if they are considered to be immune competent at presentation.

Can we change the disease biology of multiple myeloma?

Despite improvements in disease management, multiple myeloma (MM) remains incurable. Conventional treatment methods are unsatisfactory, leading to a pattern of regression and remission, and ultimately failure. This pattern suggests that one of the possible strategies for improving outcomes is continuous therapy to maintain suppression of the surviving tumor cells. Optimal management of MM requires potent agents and modalities with direct tumoricidal activity, which can also provide continuous suppression of the residual tumor to prevent disease relapse. Immunomodulatory agents exert immunomodulatory and tumoricidal effects, and cause disruption of stromal cell support from the bone marrow microenvironment. Therefore continuous therapy with immunomodulatory agents may be able to provide both tumor reduction and tumor suppression, enabling physicians to consider the possibility of incorporating continuous therapy into the treatment paradigm of patients with MM.

Single-dose pharmacokinetics of lenalidomide in healthy volunteers: dose proportionality, food effect, and racial sensitivity

PURPOSE

Lenalidomide is an immunomodulatory drug with efficacy in various hematological malignancies. The purpose of these studies was to evaluate the single-dose pharmacokinetics of lenalidomide, including dose proportionality, food effect, and racial sensitivity.

METHODS

Three studies were conducted including a total of 58 healthy subjects: a randomized, single-blind, alternating group, single-ascending dose study; a randomized, two-way crossover food effect study; and a randomized, double-blind, two-group, within-subject, single-ascending dose study.

RESULTS

Oral absorption of lenalidomide was rapid and the maximum plasma concentration (C (max)) was observed approximately 1 h post-dose. Co-administration with a high-fat meal reduced the area under the concentration-time curve (AUC) and C (max) by approximately 20 and 50 %, respectively, and delayed time to C (max) (t (max)) by 1.63 h. However, phase III trials were dosed without regard to food; therefore, clinical relevance of the food effect was minimal. The terminal elimination half-life (t (½)) was 3-4 h at doses up to 50 mg and was not affected by food. The AUC and C (max) were proportional to lenalidomide single doses (5-400 mg), and total and renal clearance were dose-independent. The R- to S-lenalidomide ratio in plasma was stable over time, approximately 45-55 % of total drug. There were no differences in pharmacokinetic parameters, dose-exposure relationship, or enantiomeric ratio, between Japanese and Caucasian subjects.

CONCLUSION

Lenalidomide displayed linear pharmacokinetics from doses 5-400 mg in healthy subjects. Although food reduced bioavailability, this was not considered clinically relevant. Lenalidomide was generally well tolerated in both ethnic groups.

Clinical spectrum, treatment, and outcome of patients with type II mixed cryoglobulinemia without evidence of hepatitis C infection

OBJECTIVE

The clinical spectrum, etiologies, and best therapeutic approaches of type II mixed cryoglobulinemia (MC) not associated with hepatitis C virus (HCV) infection have been poorly described to date. We studied the clinical presentation and outcome of patients with type II MC with no evidence of HCV.

METHODS

This was a multicenter retrospective study on the clinical presentation and outcome of patients with type II MC without evidence of HCV infection. Only patients with symptomatic MC were included.

RESULTS

Thirty-three patients were included (median followup 67.2 mo). Extensive investigations for associated diseases were performed at presentation. MC was related to an autoimmune disease in 14 patients, to a lymphoid malignancy in 4 patients, and to an infectious disease in 2 patients, while MC was classified as essential (primary) in 13. Essential MC tended to be more severe than secondary disease with, in particular, more frequent renal and peripheral nerve involvement. Most patients were treated with steroid with or without immunosuppressive agents, mainly cyclophosphamide. These treatments were unable to induce sustained remission. One patient was successfully treated with lenalidomide. Seven patients with nonmalignant MC were treated with rituximab; 2 had a sustained complete remission, 3 improved greatly but relapsed within 5 months, and 2 experienced a disease flare.

CONCLUSION

An important proportion of non HCV-related type II MC remains essential. Efforts should be made to find other etiologies than HCV, because treatments with steroid and immunosuppressants are not satisfactory, especially in severe forms. In these situations anti-CD20 therapy may present the best option but should be used with caution. New agents such as lenalidomide remain to be evaluated.