Managing Adverse Events for Patients Receiving Quadruplet Induction Regimens

Managing Adverse Events with Quadruplet Induction

Proteasome inhibitor dosing requires careful consideration, with twice-weekly bortezomib administration limited to specific clinical scenarios outside of trial protocols. Baseline peripheral neuropathy is common in many patient populations and influences proteasome inhibitor selection. Dexamethasone represents the most challenging component regarding side effects, with intentional dose reduction strategies from standard trial doses often necessary, particularly in frail or older patients.

Infection prophylaxis with anti-CD38 antibodies includes standard measures such as acyclovir for herpes zoster prevention, which also addresses proteasome inhibitor requirements. Immunoglobulin monitoring shows variable IgG levels, and replacement therapy (IVIG) may be indicated for levels below 400 mg/dL or for patients with recurrent infections. Insurance approval processes vary, with some requiring both low IgG and documented recurrent infections, though peer-to-peer discussions can often facilitate approval based on supportive data.

For Pneumocystis jirovecii prophylaxis, trimethoprim-sulfamethoxazole three times weekly provides superior coverage compared to alternatives and may offer some additional antibacterial benefit. Prophylactic antibiotic use during the first four cycles, as studied in some trials, has not been universally adopted, though trimethoprim-sulfamethoxazole may provide partial coverage for common pathogens. Routine IVIG replacement for asymptomatic hypogammaglobulinemia below 400 mg/dL without infection history varies by institutional practice, with treatment often reserved for patients experiencing recurrent infections.