Bispecific Step-Up Dosing Models in R/R MM: Institutional Approaches and Protocols

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Both panelists academic centers have successfully transitioned to fully outpatient bispecific antibody step-up dosing models, reserving inpatient administration only for the frailest patients or those with logistical barriers to outpatient care. Comprehensive supportive care protocols include universal pneumocystis jirovecii pneumonia (PJP) prophylaxis throughout treatment duration, with discontinuation criteria based on CD4+ counts above 200 cells/μL or 6 months of treatment (whichever is longer). The profound hypogammaglobulinemia associated with BCMA-directed bispecifics necessitates monthly IVIG therapy, while GPRC5D-directed agents require individualized IVIG assessment.

Hospital-at-home programs have proven invaluable for treating patients during step-up dosing periods, providing continuous monitoring between clinic visits and ensuring rapid response to treatment-related complications. This model combines the expertise of specialized myeloma teams for dose administration with the convenience and safety of home-based monitoring. Neutropenia management typically responds well to granulocyte colony-stimulating factor support when clinically indicated.

The outpatient model has demonstrated excellent safety profiles while improving patient convenience and reducing health care costs. Success depends on robust support systems, including experienced nursing staff, clear emergency protocols, and reliable patient communication systems. The experience gained from these outpatient programs provides a foundation for broader community implementation of bispecific antibody therapy, potentially expanding access to these effective treatments.