Ask AI
Back Back
Administration Considerations for Bispecific Antibodies in Multiple Myeloma
CME/CE Information

Activity

Progress
1 2 3
Course Completed
Activity Information

Physician Assistants/Physician Associates: 0.25 AAPA Category 1 CME credit

Pharmacists: 0.25 contact hour (0.025 CEUs)

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Nurse Practitioners/Nurses: 0.25 Nursing contact hour

Released: March 17, 2026

Expiration: September 16, 2026

Doris K. Hansen
Doris K. Hansen, MD

So here we have administration considerations. As we talked about, the difference in route of administration, so subcutaneous versus IV with linvoseltamab being the only IV one. And then you see the schedule can be slightly different, though it does not have to be 1, 4, 7. We can do 1, 3, 5. So slight variability can occur there. And for talquetamab, generally, if you want to go right ahead to the Q2 week dosing, you are going to have to do an extra step up to the 0.8 dose.

 

In terms of toxicities, as we talked about, CRS can happen. For example, teclistamab, talquetamab, CRS rates in the 70% range, less so in linvo and elranatamab in about the 30‑40% range, very unlikely to have severe CRS. The likelihood of ICANS is very low, though it can happen. And these patients will have cytopenias, and we have to certainly monitor for infection, and then skin, nail, oral toxicities for GPRC5D, as you see there. And you see the percentages, but generally speaking, a lot of patients, about half of them will get dysgeusia and dry mouth. And then we have seen, for example, with talquetamab, 30% of patients having weight loss and so forth, and a lot of them will have skin peeling, and this palmar-plantar erythrodysesthesia type of picture.

 

Next slide, please.

 

[00:20:54]

 

Current Recommendations for Step-up Dosing When Beginning Bispecific Antibody Therapy

 

Here we show the step-up dosing for each of the bispecific antibodies. You see there, for example, dosing slightly different for all of them.

 

Generally, for teclistamab, talquetamab, you are going to do a 1, 4, 7 type of step-up dosing until you achieve the desired dose. Linvo is once a week, and then elranatamab, 1, 4, 8. So, I mean, overall, very similar with slightly different dosing duration. And then spacing out of the dosing, depending, for example, of achievement of response, toxicity, etc.

 

Next slide, please.

 

[00:21:29]

 

BsAb Maintenance: Academic to Community Cancer Care Center

 

In terms of transitioning from academic to community, I have to say that we started out doing a lot of step-up dosing, but a lot more now, our community partners are doing step-up dosing, which is great.

 

Certainly, treatment decision-making is important between provider and patient to discuss what is this treatment? What does it entail? So, certainly, logistics, safety, efficacy are going to be important.

 

Addressing any social determinants of health, so any access issues. Delivering step-up dosing, monitoring for acute toxicities, and then, if we are doing the step-up dosing and transitioning to the community, certainly communicating between us in terms of what does that transition of care look like? What do we need to monitor for? Do patients need to continue prophylactic antibiotics, continuous immunoglobulin replacement, etc.? But, generally, you know, that communication is going to be key to improving patient outcomes.

 

Next slide, please.

 

[00:22:28]

 

Outpatient Model for Administration of Bispecific Antibodies: Patient Selection and Step-up Dosing

 

This is some data with outpatient administration of bispecific antibodies.

 

This was a small study from Emory, I believe. This was 52 patients that were included. In order for patients to be in the outpatient setting, they basically had to be within 30 minutes of the hospital. They had to have a 24-hour caretaker, and they were not allowed to drive in this particular study. But, obviously, if somebody had a lot of disease, if they had severe CRS and ICANS in the past, or they had poor performance status, well, those patients had to be inpatient. So, generally speaking, this is how the outpatient dosing schedule looked like to the right, and everybody received tocilizumab prophylaxis on day one.

 

Next slide, please.

 

[00:23:14]

 

Posttest 1: Which of the following patients would be eligible for a referral to an advanced MM center to potentially be treated with a bispecific antibody?

 

Which of the following patients would be eligible for a referral to an advanced myeloma center to potentially be treated with a bispecific antibody? I guess this is to test if you guys were paying attention, which you guys already got this.

 

  1. Patients with newly diagnosed MM and no treatment;
  2. Patients who have had only one treatment, including an IMiD and PI, and refractory to lenalidomide;
  3. Patients who have had two prior lines of therapy; or
  4. Those who have had four or more prior lines of therapy, were triple-class exposed.

 

Very good. We changed some minds. So, absolutely correct.

 

Patients who have had four or more prior lines of therapy are eligible for current FT approvals of bispecifics.

 

Next slide, please.

 

[00:24:22]

 

This is just the explanation. I think even for those of you who picked B, that is probably going to be a future indication here in the next month or so. But as it stands today, four or more prior lines of therapy is the right answer with triple-class exposure to an IMiD, PI, and a CD38 monoclonal antibody.

 

Next slide, please.

 

[00:24:42]

 

Posttest 2: Based on current indications, which of the following approved bispecific antibiotics allow for immediate biweekly dosing after completing step-up dosing?

 

Based on current indications, which of the following approved bispecific antibodies allows for immediate biweekly dosing after completing step-up dosing?

 

  1. Elranatamab;
  2. Linvoseltamab;
  3. Talquetamab;
  4. Teclistamab.

 

Very good. Talquetamab is correct and 100% got it right.

 

Next slide, please.

 

[00:25:25]

 

All right. I do not think we need to go over this. Everybody got it correct. But talquetamab, you can go immediately to Q2 weeks.

 

Next slide, please.

 

[00:25:34]

 

Discussion Topics: Considerations for BsAb Treatment

 

All right. So, here are some discussion topics. Feel free to jump in.

 

When we think about bispecific therapies, are there premedication considerations? Any thoughts? Feel free to jump in or weigh in.

 

Generally, as we talked about, right, if we are to do this in the outpatient setting, we generally do give prophylaxis with teclistamab. There has been some experience where dexamethasone may also be considered or utilized.

 

And then, do patients who have previously received BCMA-targeted CAR T respond to bispecific antibodies? Any thoughts or comments from anyone on that?

 

Speaker: Does anyone have any comments?

 

Dr. Hansen: No. Okay. No problem. Generally speaking, if somebody's received a BCMA CAR T, those patients actually respond quite well to bispecific antibodies, though it is the other way around. Generally, if you receive a bispecific before a CAR T, the CAR T might not work as well. There is some limited data there. But vice versa, when you get a bispecific post a BCMA CAR T, the data is quite robust from the clinical trials and real-world settings showing efficacy in that scenario.

 

When are patients ready to be transitioned to a community setting? Well, hopefully, our community doctors are already starting to do step-up dosing, but generally, we transition them after the step-up dosing.

 

And then, what strategies can community practices employ to ensure a smooth transition of care? Any thoughts there? And then, we can include the last question here: what patient-specific issues may arise?

 

I will start us off. Let us know if there are any comments.

 

But generally speaking, I really think communication is key between academics and community and making sure that we follow our guidelines, for example, for ACV prophylaxis, you know, acyclovir or HSV prophylaxis. We certainly do consider PCP prophylaxis and monthly IVIGs are going to be critical for these patients.

 

Next slide, please.

 

[00:28:16]

 

InterACT Team Discussion

 

What challenges are you encountering in your clinic with integrating bispecific antibodies into treatment for patients with multiple myeloma? Any thoughts? And how are you addressing them?

 

Speaker: Go ahead.

 

Speaker: For these patients, are the costs concerning for the medications you are dispensing and everything that you are distributing fine? Because apparently, with the new CMS rate, CMS standards for the prescription drugs for the co-pay itself, having a deductible max of, like, what, 20? The truth of the $29,000, how does that really play with this?

 

Dr. Hansen: Yes, I am sorry. Yes, it is very difficult for me to hear. It is okay. I think if I understood it, it has to do something about reimbursement, right? And making sure that the patients, you know, are able to receive these therapies from a reimbursement standpoint. So, I think that is certainly a very valid point.

 

You know, other challenges or considerations certainly could include: how do you feasibly treat all of these patients? How do you logistically? For us here in academics, we have inpatient, outpatient, 24-hour coverage. We have very standardized SOPs, standard operating procedures. But is that the same in the community? Or who admits them? What happens if they have CRS? I am sure those are considerations.

 

And then barriers to patients completing therapy. You know, it could be that they have cytopenias, they have infections. So, certainly, like, comorbidities or toxicity profile could be considerations.

 

Any additional thoughts or barriers to completion of therapy that you have noticed?

 

Speaker: Change in care. So, like, intrinsic. So, access to care is going to be difficult.

 

Dr. Hansen: Yes. No, that is an excellent, excellent point.