Subcutaneous Daratumumab May Be More Feasible for Older Patients

The subcutaneous formulation of daratumumab (Darzalex), known as daratumumab and hyaluronidase-fihj (Darzalex Faspro), requires less premedication and can lead to better outcomes for patients with multiple myeloma, according to an expert.

Chad Robertson, PA-C, a senior physician assistant at the Mount Sinai Multiple Myeloma Center of Excellence, explained that daratumumab and hyaluronidase-fihj is less likely to cause injection-site reactions in patients with multiple myeloma.

However, he still advises premedicating patients with dexamethasone, acetaminophen, famotidine, loratadine, and/or diphenhydramine. After the first injection, he continued, premedication may be less necessary, as long as patients are not reacting poorly to treatment.

Due to the speed of subcutaneous administration, daratumumab and hyaluronidase-fihj is a much faster and easier method of treatment for many patients, and may make treatment more tolerable and easy to accommodate for older patients, patients with higher likelihood of infusion reactions, or patients who live further from care centers.

Transcript

[Subcutaneous administration of daratumumab] is much better [than intravenous (IV) administration] for a couple different reasons. One, it’s faster. Two, it’s safer. It’s the same level of effectiveness, but speed and safety for patients is incredibly valuable.

When it was the IV [administration], it was over a couple of hours that it was administered, and there was a very large risk of infusion reactions. As you were taking the medications, you always had to worry about the premedications. Premedications were going to be your [dexamethasone], your Tylenol [acetaminophen], your Pepcid [famotidine], your Claritin [loratadine] or Benadryl [diphenhydramine].

What we found with the [subcutaneous] administration is the chance of infusion reaction is much lower. You still do see the occasional reaction [in] patients who are receiving it in their first cycle. We’ve now gotten to the point, though, where we will premedicate for that first cycle, and we’ll still observe after the first administration, but then after that first cycle, we cut back on the [premedications]. It’s much more of a “get in, get out” type of thing, which is great. That kind of lends itself to the patient safety perspective. Fewer chances of reaction make for happier patients.

First-time administration, it’s good to, as mentioned, premedicate, which is just going to be the antihistamine support, [or] the [acetaminophen]. With regards to if there were any reactions, typically, it’s going to be sort of the flulike symptoms that you see with a lot of infusion reactions.

You [might] get a delayed reaction the next day. There are some doctors who will just automatically give [4 mg or 8 mg of dexamethasone] for the patient to take at home [on the] morning after, just to prevent anything, just something really light like that. But then there are others that [find] it’s so rare that it’s not necessary.

The best part about this medication is it’s so well tolerated. We’ve got some elderly patients that really can’t tolerate a lot of toxicities that might infect the bone marrow or other toxicities, and if it’s somebody who’s really elderly, we can give [the patient] [daratumumab and hyaluronidase-fihj].

The other great thing about the [daratumumab and hyaluronidase-fihj], or the [Darzalex Faspro], is the frequency of it compared to so many other drugs. It’s got a really long half-life. It stays in the body for a long time. It’s a drug that we can give once a month once you build up to it. There are some doctors that even just give it once every 2 months, depending on the case, the response to treatment, and just the general wellbeing of an elderly or frail patient.

To be able to tell a patient, “Hey, we just need to see you once a month,” can really go a long way towards the quality of life of elderly patient who have trouble getting out of the house.

Work with the patients. Find out what they’re looking for, find out what they need. Find out what their background is, same as you would with any other drug. Keep in mind just [what their infection history is]. Are they at risk for infection when first administering it?

Go lightly. And by go lightly, go “smartly,” I think, is the better word. And go smartly with [premedications]. Go smartly with observation. While reactions are much less with this compared to the [IV administration], they’re still out there. You don’t want to get caught flat-footed when a patient is starting treatment, because it’s an easy way to lose trust with a patient. So just do it right those first couple times, and then it really grows. It gets really easy, and hopefully the efficacy is there for years.

This transcript has been edited for clarity and conciseness.