Dr Banerjee on Bispecific Antibody Treatment De-Escalation Strategies in Relapsed Myeloma

“[We are looking at ways to] de-escalate treatment. How do we get the drug started more quickly for patients and spend less time in the hospital?”

Rahul Banerjee, MD, FACP, assistant professor, Clinical Research Division, Fred Hutchinson Cancer Center; assistant professor, Division of Hematology and Oncology, University of Washington, discusses the need for treatment de-escalation strategies with the use of bispecific antibodies in patients with relapsed multiple myeloma.

Time toxicity is a significant concern in multiple myeloma management, particularly in the relapsed setting, Banerjee begins. Patients often spend substantial time in the clinic for scheduling, blood work, intravenous immunoglobulin (IVIg) administration, and other treatments, which affects their quality of life, he explains. However, efforts are underway to address this issue by de-escalating treatment regimens and reducing the frequency of clinic visits, he says.

Current bispecific antibodies require step-up dosing, which involves prolonged inpatient observation, to mitigate the risk of developing cytokine release syndrome, Banerjee explains. The duration of this observation and the timeline for transitioning to less frequent dosing vary across agents, he adds. For example, treatment with teclistamab-cqyv (Tecvayli) requires sustained complete response for 6 months before transitioning to biweekly dosing, according to Banerjee. Real-world data also indicate that oncologists are de-escalating bispecific antibody treatment more rapidly than protocol guidelines suggest, often transitioning to monthly dosing in individual patients to minimize infections, adverse effects, and clinic visits, he reports.

Studies like the phase 2 LimiTec trial (NCT05932680) are exploring time-limited therapy with teclistamab and aim for treatment durations of 6 to 9 months followed by careful observation, Banerjee states. This approach could significantly reduce the burden of lifelong bispecific antibody therapy, which currently involves weekly clinic visits for up to 2 years or until disease progression, he explains. Additional research into quarterly dosing schedules, which could further reduce time toxicity, is ongoing, he says.

Although CAR T-cell therapy requires more upfront logistical effort, it offers the advantage of being a one-time infusion with minimal follow-up beyond monthly visits for blood work or IVIg, Banerjee continues. In contrast, bispecific antibodies demand more frequent clinic visits but may become more competitive with the evolution of time-limited or de-escalated regimens, he concludes.