Q&A: COVID-19 continues to affect multiple myeloma care, patients
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Key takeaways:
- Certain patient populations remain vulnerable to COVID-19 despite vaccinations and other precautions.
- A new class of immunotherapy has been approved for multiple myeloma that targets the B-cell maturation antigen.
Despite widespread vaccinations and preventive measures in place, the continued circulation of the COVID-19 virus remains a challenge for clinicians and patients affected by multiple myeloma.
Studies have shown that poorly controlled myeloma is one of the biggest risk factors for fatal COVID-19, and while much of the world is no longer centered around the virus, the health of patients with multiple myeloma can be compromised if they contract COVID-19.
Healio spoke with Samir Parekh, MD, professor of medicine and oncological sciences and director of translational research in myeloma at Tisch Cancer Institute at Icahn School of Medicine at Mount Sinai, on how COVID-19 continues to affect immunocompromised patients.
Healio: With the world moving past the pandemic despite the continued circulation of COVID-19, how does the virus impact multiple myeloma care?
Parekh: I think the world seems to have moved past the pandemic, but certain vulnerable patient populations still, unfortunately, continue to remain vulnerable to COVID and face recurrent COVID infection despite having vaccinations. We see this in our clinic with our myeloma patients. So, I don't think we can say that the pandemic has completely passed for all our myeloma patients. For example, we saw a wave of COVID after Thanksgiving, and a similar increase in COVID is now being observed after Christmas travels. And this is despite having advised most of our patients to get vaccinations and be careful, especially if they have low antibody levels and are on active immune suppressive chemotherapy.
Healio: Has there been any new important research about the impact COVID-19 may have on multiple myeloma outcomes?
Parekh: In the past year, there were a few notable papers on COVID particularly relevant for myeloma patients. One is that there have been new bispecific antibodies. This is a new class of immunotherapy that has been approved for multiple myeloma, and the bispecific antibodies target an antigen called BCMA, or B-cell maturation antigen. It is particularly associated with COVID infection because of immunosuppression. In the clinical trials that led to the approval, there was a fairly high percentage of patients that developed COVID, and this is something that the patients that get these new therapies should be careful about. I think that they should be careful about infection, particularly on these treatments. Our own research has shown that this is definitely true.
It is also important for patients on anti-CD38 therapy, which is commercially a drug called daratumumab (Darzalex, Janssen Oncology). So, we have to be careful when patients are on these treatments, and counsel them appropriately to maintain precautions and make sure that they are getting all the COVID boosters as they come up. There are also strategies like IV immunoglobulin that help boost the patient's immune system. So, all of these things are important, and we are trying to help patients get through these treatments in as safe a manner as possible.
Healio: Does COVID-19 and/or the vaccination impact treatment in multiple myeloma?
Parekh: We are finding the way the clinical trials were done with the newer immunotherapies, the duration of therapy was not clearly defined and instead was giving the treatments until the patients relapse. As these treatments also cause immunosuppression, to help actually decrease the risk for infection if the patients are in remission, many physicians are reducing the frequency of these new bispecifics and are giving treatment breaks. So, yes, it is definitely impacting treatment. Companies are now designing clinical trials that have a fixed duration of treatment, so that we understand whether we need to give these treatments for a very long time, or we can give them for shorter duration and still achieve the same benefit.
Healio: How did the pandemic impact your approach to myeloma care?
Parekh: I weigh the risk and benefit of the treatment more carefully while prescribing the chemotherapy. Particularly the immune suppression from the medications is something that we cannot take lightly in the case of myeloma patient, who are frequently elderly and may already have immune compromised from their myeloma. So, I think that I definitely have been much more considerate about this since the pandemic.
Healio: What advice do you have for clinicians managing patients with multiple myeloma who have a suspected or confirmed case of COVID-19?
Parekh: My recommendation would be that they evaluate the patient and the need for antiviral therapy, such as Paxlovid (nirmatrelvir/ritonavir, Pfizer), as they would any other individual in their practice. After the patient is over the acute course of COVID, there may be certain additional considerations such as giving IV immunoglobulin prophylaxis. We have had certain individuals who have had persistent COVID infection for months, and therefore, we have actually documented this and received a grant from the NIH to study these individuals, as the virus can mutate in the same patient and become more vigilant and infect other patients around them.
We had a case of a patient that infected four other patients and even members of the community. In these patients, persistent infection led to mutations that made the virus evolve to become more infectious. This is concerning, as this might lead to the next pandemic, without the need of a reservoir.
We are doing research on this with the help of the microbiologists and virologists at Sinai. If you have patients with persistent infections, please let us know. We have the technology to sequence the virus and determine if it is indeed becoming more infectious.
For more information:
Samir Parekh, MD, can be reached at samir.parekh@mssm.edu.
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