Addressing practical challenges with bispecific antibody therapy in multiple myeloma

Bispecific antibodies (bsAbs) have demonstrated impressive standalone effectiveness in relapsed and refractory multiple myeloma, as evidenced by clinical trials and real-world findings. Current clinical studies are investigating these drugs as both monotherapies and in combination treatments for earlier stages of myeloma, including newly diagnosed cases.

With many options available in clinical settings, several questions emerge: How can one bsAb be chosen over another? What is the best way to administer bsAbs, including initial step-up and continuous dosing schedules? How can unique toxicities be managed, and what strategies should be used to address disease relapses following bsAb treatment?

Tocilizumab is being investigated in the prevention of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Steroids can be used to safely treat CRS in myeloma patients on bsAb therapy. This may allow a safe outpatient step-up dosing program. Despite improved infection management with intravenous immunoglobulin prophylaxis, infection risks continue as long as patients are on therapy. This indicates alternative strategies like less frequent dosing or finite duration therapy are needed. Optimal management of disease relapse after bsAb therapy and the sequencing of bsAb and chimeric antigen receptor (CAR) T-cell therapies require further investigation.