Immunomodulatory treatments for multiple myeloma
Fact-checked by Immunomodulatory drugs (IMiDs) are a mainstay treatment option for the rare blood cancer multiple myeloma.
Multiple myeloma, or more simply myeloma, arises when plasma cells, a type of antibody-producing immune cell, grow out of control in the bone marrow, the spongy material inside bones.
IMiDs are usually used in combination with other myeloma treatments to help kill these cancerous cells. They are used at various stages, including in newly diagnosed patients, as a maintenance therapy after a stem cell transplant, and in people with relapsed or refractory myeloma, whose cancer has returned after or failed to respond to other treatments.
What are immunomodulatory treatments?
The exact mechanisms of IMiDs in myeloma are not fully established. They are thought to work in multiple ways, including:
- directly killing myeloma cells
- activating immune cells that can naturally target and kill cancerous cells
- interfering with new blood vessel formation, a process cancer cells use to survive and grow
- inhibiting the production of inflammatory signaling molecules
- altering the bone marrow environment in ways that suppress myeloma cells’ ability to take over
Altogether, these mechanisms enable IMiDs to help kill myeloma cells and slow cancer growth.
Immunomodulatory treatments for multiple myeloma
There are three IMiDs approved in the U.S. for treating myeloma:
All of these medications are taken orally in capsule form and are available as generics. They are usually combined with other medications, particularly the corticosteroid dexamethasone, and are generally taken daily in monthlong cycles, with periods of rest in between.
Thalomid was the first medication in the class to be approved for myeloma. Revlimid and Pomalyst were later developed to work similarly, with enhanced therapeutic effectiveness and fewer side effects.
Revlimid is now considered a standard of care treatment in both newly diagnosed and relapsed/refractory myeloma settings. Pomalyst is most often used for people with advanced myeloma who have not had a good or sustained response to several other medications, including Revlimid.
In the U.S., Thalomid is not used as often nowadays, but still sometimes plays a role in myeloma treatment regimens. It is the most cost-effective IMiD, so it’s used more commonly in resource-limited countries or for people with insurance coverage limitations.
Side effects
The side effects of IMiDs depend on the specific medication that’s used, but could include:
- fatigue or weakness
- constipation
- nausea
- shortness of breath
- fever
- low blood cell counts
All IMiDs come with a boxed warning on the label that they may cause serious birth defects or fetal death if used during pregnancy. For that reason, they are only available in the U.S. through restricted access programs. Female patients with reproductive potential must obtain a negative pregnancy test before starting any IMiD and use two reliable methods of contraception throughout treatment.
These medications also come with boxed warnings that they can increase the risk of serious blood-clotting issues. For this reason, they may be given along with clot-preventive therapies.
IMiDs can cause serious immune reactions, or hypersensitivity, and should not be used by people who have had such reactions in the past.
Other side effects and risks may depend on the specific medication and regimen. Patients should discuss with their healthcare providers what they might expect in their individual case.
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