Bispecific Step-Up Dosing Models in R/R MM: Real-World Protocols and Institutional Practices

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The evolution of bispecific antibody administration has transitioned from mandatory prolonged inpatient stays to hybrid and outpatient models as institutional experience has grown. Similar to the historical progression with daratumumab, initial safety concerns requiring inpatient monitoring have given way to more practical outpatient approaches as clinicians became comfortable with predictable toxicity patterns. The key to successful transitions involves establishing comprehensive protocols, educating all health care team members, and ensuring 24-hour availability of specialized care.

Successful outpatient step-up dosing programs require several critical components: institutional champions to lead implementation, dedicated nursing staff familiar with bispecific toxicities, 24-hour on-call coverage, and established urgent care pathways for patients experiencing adverse events. Patient education remains paramount, including detailed instructions on temperature monitoring, when to call for assistance, and availability of take-home medications such as dexamethasone for immediate symptom management before seeking medical care.

Community partnership models focus on risk stratification, with academic centers handling high-risk step-up dosing phases before transitioning stable patients to community providers for maintenance therapy. This approach requires community oncologists to become familiar with infection management and late-onset toxicities whereas academic centers retain responsibility for the highest-risk treatment phases. The goal is democratizing access to these effective therapies while maintaining safety standards through collaborative care models.