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Treatment Name: CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone)

CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone) is a Chemotherapy Regimen for Multiple Myeloma (MM)

How does CyBorD work?
Each of the medications in CyBorD is designed to kill or slow the growth of myeloma cells.

Cy - Cyclophosphamide (Cytoxan)
Bor - Bortezomib (Velcade)
D - Dexamethasone

Alternative name: VCdcybord

V - Velcade
C - Cytoxan (cyclophosphamide)
d - dexamethasone

Goals of therapy:
CyBorD or VCd or cybord is given to alleviate symptoms and slow the progression of multiple myeloma. After treatment, patients who respond to CyBorD are typically monitored in the clinic using blood tests, continue on to maintenance therapy, or proceed to bone marrow transplant.

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Schedule

  • Cyclophosphamide (tablets or capsules) by mouth once daily on Days 1, 8, 15, and 22
  • Bortezomib (Velcade) subcutaneous injection on Days 1, 4, 8, and 11
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4, then 9, 10, 11, 12, then 17, 18, 19 and 20

Bortezomib is usually given in an outpatient infusion center, allowing the person to go home afterwards. Cyclophosphamide and dexamethasone are usually taken at home. On occasion, CyBorD may be given in the hospital if someone is too sick.

CyBorD is repeated every 28 days. This is known as one Cycle. Each cycle may be repeated up to 4 times, depending upon the stage of the disease. Duration of therapy may last up to 4 months, depending upon response, tolerability, and number of cycles prescribed.

There are various alternative dosing schedules for CyBorD.

Click here for common starting doses.

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Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects with CyBorD are shown here. Side effects sometimes have percentage ranges [example: 13 – 24% cause low white blood cells] because they differed between clinical studies:

  • Increased bleeding risk [low platelet count] (25%)
  • Low white blood cells (13 - 24%)
  • High blood sugar (13%)
  • Anemia [low red blood cell count] (12%)
  • Low blood potassium (9%)
  • Nerve pain (7 - 18%)
  • Blood clots (7%)
  • Diarrhea (6%)

Approximately 6 - 9% of patients discontinue CyBorD due to unacceptable side effects.

Side effect videos Side Effect Videos
DiarrheaDiarrheaFatigue Fatigue BleedingBleedingPainPainNeutropenic FeverNeutropenic FeverBlood ClotsBlood ClotsAnemiaAnemia

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Monitoring

How often monitoring needed?
Labs (blood tests) may be checked before treatment and periodically during treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), serum free light chains (FLC), quantitative immunoglobulins, beta2-microglobulin, serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), cytogenetic analysis (karyotyping and FISH testing), plus any others your doctor may order.

How often is imaging needed?
Imaging may be checked before treatment and then periodically during treatment to assess how the chemotherapy is working. Imaging may include: bone surveys, X-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI), or positron emission tomography (PET) scans.

How might blood test results affect treatment?
Depending upon the results, your doctor may advise to continue chemotherapy as planned, or delay or switch therapy.

On occasion, if cyclophosphamide causes a decrease in the white blood cell (WBC) count to an unsafe range, bortezomib and dexamethasone may be able to be continued, depending upon physician preference and goals of therapy.

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ChemoExperts Tips

  • Bortezomib (Velcade) can cause reactivation of herpes simplex virus (HSV) or varicella zoster virus (VZV).  Prophylactic (preventative) anti-viral medications such as acyclovir (Zovirax®), valacyclovir (Valtrex®), or famciclovir (Famvir®) should be taken during treatment
  • Additional medications that may be prescribed include Bactrim® (Sulfamethoxazole/Trimethoprim; unless you have a sulfa allergy) to prevent Pneumocystis Pneumonia and omeprazole (Prilosec®, or a similar medication) to prevent ulcers from dexamethasone
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for multiple myeloma. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone). Depending upon your income, they may be able to help cover the cost of:

  • Cyclo­phos­phamide
  • Bortezomib
  • Dexamethasone

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with CyBorD (Cyclo­phos­phamide + Bortez­omib + Dexa­meth­asone)

Individual Drug Label Information

Cyclo­phos­phamide (Cytoxan®)

  • Cyclophosphamide comes in an oral tablet or capsule 
  • May be taken with food to minimize nausea or vomiting. It should be swallowed whole 
  • If you miss a dose, contact your doctor or pharmacist to determine whether you should still take it or skip it because taking it too late may affect other medications 
  • Store at room temperature 
  • May decrease the ability to become pregnant. Fertility preservation is recommended in couples wishing to become pregnant. Women should avoid becoming pregnant while taking cyclophosphamide as it may harm the baby 
  • A smaller dosage may be required for patients receiving hemodialysis 
  • Has been linked to the development of other cancers in a small number of people 
General Cyclophosphamide (Cytoxan) Side Effects 
  • Low white blood cell count which can increase the risk of infection 
  • Nausea or vomiting, which can be acute (first 24 hours) or delayed (Days 2 – 5) 
  • Hair loss, which is usually reversible. Hair may grow back a different color or texture (curly vs. straight) 
  • Click on the cyclophosphamide (Cytoxan) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Bortezomib (Velcade®)

  • Bortezomib can be given either as an intravenous (I.V.) infusion or more commonly as a subcutaneous (under the skin, “SubQ”) injection
  • Dosage adjustments may be required for liver dysfunction, low blood counts, or nerve pain
  • Will cause death if administered into the spinal fluid
  • Green tea and green tea extracts may decrease the effectiveness of bortezomib and these should be avoided.
  • Avoid dietary supplementation with ascorbic acid (Vitamin C), which also includes multivitamins that contain ascorbic acid. Normal dietary intake of ascorbic acid does NOT need to be changed
  • Avoid over-the-counter natural products such as St. John’s Wort
General Bortezomib (Velcade) Side Effects 
  • May cause or worsen nerve pain and is more common if bortezomib is given intravenously than subcutaneously
  • Can cause decreases in platelets, red blood cells, and white blood cells leading to increase risk of bleeding, fatigue, and infection
  • May cause reactivation of herpes simplex virus (HSV) or varicella zoster virus (VZV). Prophylactic anti-viral medications should be taken during therapy with bortezomib
  • Can worsen symptoms of heart failure
  • May cause redness or irritation around injection site if given subcutaneously
  • Click on the bortezomib (Velcade) package insert below for reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaFatigue Fatigue BleedingBleedingConstipationConstipationPainPain

See DailyMed package insert.

Dexamethasone (Decadron®)

  • Dexamethasone is supplied as an oral tablet or oral liquid
  • Dexamethasone may increase the risk of infection. Depending upon how much dexamethasone is taken, antibiotics may be prescribed to help prevent infection
  • Should be taken with food and with a large glass of water to avoid stomach irritation or ulcers
  • Should be taken before 6 p.m. when possible, to avoid trouble falling asleep
  • May decrease the response to vaccines; vaccines may need to be repeated at a later date to obtain maximal response
  • If taken daily for several days or weeks, the dose of dexamethasone may need to be gradually decreased (tapered) to avoid withdrawal symptoms
  • If you miss a dose, take the next dose as soon as possible
  • Should be stored at room temperature
General Dexamethasone (Decadron) Side Effects
  • May cause high blood sugar, weight gain, irritability, high blood pressure, difficulty sleeping, stomach ulcers, bone loss, muscle weakness
  • Click on the dexamethasone (Decadron) package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

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References

1. Reeder CB, Reece DE, Kukreti V, et al. Cyclophosphamide, bortezomib and dexamethasone (CyBorD) induction for newly diagnosed multiple myeloma: High response rates in a phase II clinical trial. Leukemia. 2009;23:1337-1341.

2. Reeder CB, Reece DE, Kukreti V, et al. Once versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma. Blood. 2010;115:3416-3417.

3. Kumar S, Flinn I, Richardson PG, et al. Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood. 2012;119:4375-4382.

Created: September 1, 2015 Updated: January 4, 2017

What is Multiple Myeloma (MM)?

Multiple Myeloma is a disease of the white blood cells, called plasma cells, found in the blood or bone marrow. Plasma cells are a type of white blood cell known as a B-lymphocyte.

Sometimes plasma cells form collections on bone and weaken or destroy it. These are known as "lytic lesions". Multiple Myeloma is a rare condition with an unknown cause. The stage can vary at diagnosis and throughout treatment. Staging is based on the international staging system (ISS). The type and effectiveness of the treatment may depend upon the stage.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

Alternative Schedule #1 (28-Day Cycle)

  • Cyclophosphamide 300 mg/m2 by mouth daily on Days 1, 8, 15, and 22
  • Bortezomib 1.5 mg/m2 subcutaneous injection on Days 1, 8, 15, and 22
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1 - 4, 9 - 12, and 17 - 20 for Cycles 1 and 2, then on Days 1, 8, 15, and 22 for cycles 3 and 4.

Cyclophosphamide may be taken at home or given in clinic. Dexamethasone is usually taken at home but may be given in clinic during Cycles 3 and 4.

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability

Alternative Schedule #2 (21-Day Cycle)

  • Cyclophosphamide 500 mg/m2 by mouth daily on Days 1, 8, and 15 only
  • Bortezomib 1.3 mg/m2 subcutaneous injection on Days 1, 4, 8, and 11
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1, 8, and 15 only

Bortezomib is usually given in an outpatient infusion center, allowing the person to go home afterwards. Cyclophosphamide and dexamethasone are usually taken at home.

This CyBorD cycle is repeated every 21 days (instead of 28 days).

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability

Clinical Trials

If you are interested in reading the clinical trials results, please click on references below:

1. Reeder CB, Reece DE, Kukreti V, et al. Cyclophosphamide, bortezomib and dexamethasone (CyBorD) induction for newly diagnosed multiple myeloma: High response rates in a phase II clinical trial. Leukemia. 2009;23:1337-1341.

2. Reeder CB, Reece DE, Kukreti V, et al. Once versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma. Blood. 2010;115:3416-3417.

3. Kumar S, Flinn I, Richardson PG, et al. Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood. 2012;119:4375-4382.

Common Starting Doses (28-Day Cycle)

  • Cyclophosphamide 300 mg/m2 (tablets or capsules) by mouth once daily on Days 1, 8, 15, and 22
  • Bortezomib (Velcade) 1.3 mg/m2 subcutaneous injection on Days 1, 4, 8, and 11
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4, then 9, 10, 11, 12, then 17, 18, 19 and 20

NOTE: Some doctors may change cyclophosphamide to the Intravenous (I.V.) route at the same dose as the oral dose

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

  • Cyclophosphamide 500 mg/m2 by mouth daily on days 1, 8, and 15
  • Bortezomib 1.3 mg/m2 subcutaneous injection on days 1, 4, 8, and 11
  • Dexamethasone 40 mg (ten x 4 mg tablets) by mouth on days 1, 8, and 15

Bortezomib is usually given in an outpatient infusion center, allowing the person to go home afterwards. Cyclophosphamide and dexamethasone are usually taken at home.

CyBorD is repeated every 21 days. This is known as one cycle. Each cycle may be repeated up to 4 times, depending upon the stage of the disease. Duration of therapy may last up to 4 months, depending upon response, tolerability, and number of cycles prescribed.