How to select drug combinations for multiple myeloma treatment? 7

How to select drug combinations for multiple myeloma treatment? 7

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Well, at least six new medicines for multiple myeloma were approved in the last five years. Two drug regimens now have been replaced by three or four drug combinations and response rates. As you mentioned, that close to 100% complete remission happens in over 50% of multiple myeloma patients. So how to identify The most efficient combination of new drugs for multiple myeloma, in treatment induction and also in maintenance treatment regimens. It's a good it's a good problem, problem of success that a lot of treatments are giving us 100% response rate. So because we get 100% response rate, we are beginning to move on to determining what is called minimal residual disease negativity. Now to simply describe this MRD when we do currently, or we were doing in the past recent past, determination of response, and we call complete response, we do bone marrow and try to see if there are no myeloma cells in the bone marrow, that's one of the requirements to call somebody to be in complete remission. Now, that determination of bone marrow negativity was based on regular pathological examination microscope and our ability to find myeloma cells in that setting was around one cell in 100. So if there's one myeloma cell in the bone marrow in 100 cells, we might be able to find it by doing the staining we do. And there was our standard till recently. Now the newer technologies, sequencing based technology, and also doing multicolor, 10 and 12-color flow cytometry has allowed us to have an ability to identify one myeloma cell in a million. So 10,000 more deeper estimation of myeloma cell presence. And so utilizing such a very sensitive method, we are redefining the response. And so our aim now is not to get complete remission alone. Dr. Nikhil Munshi, MD.: But to get MRD negativity, which doesn't happen in 100%, yet, it happens in around 50%. And so using such methodologies, we are beginning to compare multiple drug combination we have clearly shown in many studies, three drugs are better than two drugs. And the three drugs usually involve one steroid, but the main two drugs end up being the proteasome inhibitor, and an immunomodulating drug, so that's very clear. Now, we are all greedy, we want to get more and more, we want to get 100% patients having the best response. So what we began to do is combining the fourth drug, which is an antibody that targets a cell surface molecule called CD38. And so enticing these CD38 antibodies have become important component of four drug regimen three that are described in the fourth antibody. And now there are studies multiple studies that shows that for drugs provide better responses and PFS compared to three drugs. So for drugs are becoming better, but because there are multiple permutation combination available, there are many studies ongoing simultaneously in different countries, different regions, asking questions, which one may be better, most likely, general analysis would be the difficult mind one and ICD 38 and the body one producer many better and one immunomodulatory drug with steroid. Those four drugs provide currently the best induction response usually around 50% MRD negativity overall 100% response rates.