Expert Multiple Myeloma Care: Clinical Insights for Oncology Nurses

Modern multiple myeloma management increasingly relies on combinations featuring daratumumab (Darzalex) in its intravenous and subcutaneous formulations (daratumumab hyaluronidase-fihj; Darzalex Faspro) that, while complex, have been shown to significantly improve patient-reported quality of life over the course of treatment. According to Natalia Neparidze, MD, these advancements are transforming the disease from an acute malignancy into a manageable chronic condition, offering many patients a path toward a functional cure. In an interview with Oncology Nursing News, Neparidze details how these shifts impact clinical practice and patient outcomes.

Neparidze is an associate professor of internal medicine (hematology) at the Yale School of Medicine and serves as the leader for the myeloma clinical research team. She is currently involved in research assessing the real-world efficacy and quality of life outcomes of patients receiving daratumumab among other studies. With extensive experience in both basic science and clinical trials, she provides a comprehensive look at the practical aspects of modern myeloma care.

Oncology Nursing News: How do daratumumab combinations impact quality of life for patients with multiple myeloma?

Neparidze: Generally, daratumumab is very well tolerated if clinicians and nurses are well-attuned to premedication regimens. Infusion reactions don’t usually happen with subcutaneous administration with appropriate premedication. What we are observing in our current study — which involves, in part, newly diagnosed patients with the adoption of daratumumab frontline regimens and CD38 monoclonal antibody frontline regimens as well as a relapsed cohort — is that with the initiation of treatment, patients are very sick initially. They may have high comorbidity scores and pain scores, but quality of life improves with the implementation of daratumumab-based regimens. As we follow their quality-of-life patient-reported outcomes, we see improvement in multiple points of their quality-of-life parameters at 3, 6, 12, and 18 months of treatment. This is encouraging.

What safety signals should oncology nurses monitor when administering subcutaneous daratumumab?

When intravenous daratumumab first became available, infusion-related reactions occurred in over 50% of cases. Nowadays they happen in less than 10% of individuals with the subcutaneous route. Nursing staff needs to be well aware and prepared for responding to infusional injection site reactions. Appropriate premedication with H1 and H2 blockers, leukotriene inhibitors, and steroids are widely used as premedication. With that cocktail of premedication, almost no one develops a reaction.

Which patients are more likely to experience a reaction to daratumumab-based regimens, and how should those be managed?

We have seen grades 2 to 4 reactions occasionally, especially when patients have a large tumor burden, or if they have delayed febrile reactions. When patients go home, they may experience febrile reaction within 24 hours. Education of patients and nurses is important for this reason, and we frequently make a dose of dexamethasone available at home. This can be treated with drinking fluids and taking dexamethasone or acetaminophen [Tylenol] at home to reduce the fever. If the patient is neutropenic, they need to be evaluated more urgently.

If the reaction develops, it will happen within the first cycle, or the first 2 doses of treatment; after that, it’s no longer expected.

Later on, the main concern is the risk of infections. There is hypogammaglobulinemia that needs to be monitored. IVIG supplementation, especially with the quadruplet and triplet daratumumab combinations, will likely be necessary in the majority of patients. This has to be administered proactively when the immunoglobulin G level reaches 400 or less.

What are the vaccination recommendations for patients on active myeloma therapy?

Patients with myeloma on active treatment may not mount an adequate humoral immune response in terms of their immune antibodies. … They can't receive live vaccines while on daratumumab, but they can receive all the killed versions of vaccines they need, including influenza, COVID-19, and pneumococcal vaccinations. Vaccines save lives in patients with myeloma. Even though they may not mount an antibody response, there is a certain degree of cellular immune response that occurs with vaccination which is hugely beneficial.

This transcript has been edited for clarity and conciseness.