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Treatment Name: DPd (Daratumumab + Pomalidomide + Dexamethasone)

DPd (Daratumumab + Pomalidomide + Dexamethasone) is a Treatment Regimen for Multiple Myeloma (MM)

How does DPd work?

Daratumumab is an antibody (a type of targeted drug therapy) that attaches to a specific protein commonly found on the surface of myeloma cells. When daratumumab binds to this protein on myeloma cells it marks the cell for destruction by your immune system.

Pomalidomide and dexamethasone are designed to kill or slow the growth of myeloma cells.

DDaratumumab (Darzalex®)
PPomalyst® (Pomalidomide)
dDexamethasone (Decadron®)

Alternative names: Dara/Pom/Dex, Dara-Pom-Dex

What are the goals of therapy?

DPd is typically given to patients who have failed at least 2 therapies, including lenalidomide (Revlimid®) and a proteasome inhibitor (bortezomib, carfilzomib, ixazomib). It is not given to cure multiple myeloma but is given to slow the progression of the disease and to improve symptoms of myeloma.

Schedule

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How is DPd therapy for multiple myeloma given?

  • Daratumumab intravenous infusion once weekly (Days 1, 8, 15, and 22) during Cycles 1 and 2, then once every other week (Days 1 and 15) during Cycles 3 through 6, then once monthly thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions
  • Pomalidomide 4 mg tablet by mouth daily for 21 days continuously on days 1 through 21, followed by 7 days break where pomalidomide is NOT taken (days 22 through 27)
  • Dexamethasone:
    • 40 mg (ten 4 mg tablets) by mouth once weekly (Days 1, 8, 15, and 22)
             OR
    • 20 mg (five 4 mg tablets) by mouth once weekly (Days 1, 8, 15, and 22)

Estimated total infusion time for this treatment:

  • Because of the possibility of experiencing infusion reactions with daratumumab, Cycle 1 Day 1 may take up to 8 hours. If you do not experience any infusion reactions with the first infusion, Cycle 1 Day 8 may take up to 6 hours. If you do not experience any infusion reactions during the first two infusions of daratumumab, the infusion time on the remaining days daratumumab is given may take up to 4 hours. In some cases, if patients tolerate the first few daratumumab infusions well, subsequent infusions can be given over 90 minutes
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

Pomalidomide is a human teratogen. In order to decrease the risk of embryo-fetal exposure, pomalidomide is available only through a restricted distribution program (Pomalyst® REMS).

DPd is usually given in an outpatient infusion center, allowing the person to go home afterwards. In some cases, the first dose of daratumumab may be given inpatient.

DPd is repeated every 28 days. This is known as one Cycle. Each cycle may be repeated until the regimen no longer works or until unacceptable side effects occur.

Click here for the common starting doses.

Side Effects

What are the most common side effects from DPd for multiple myeloma?

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 DPd side effects are shown here.

  • Low white blood cells [neutropenia] (80%)
  • Low red blood cells [anemia] (54%)
  • Fatigue (52%)
  • Diarrhea (43%)
  • Low platelets [thrombocytopenia] (42%)
  • Cough (38%)
  • Constipation (34%)
  • Shortness of breath (32%)
  • Nausea (31%)
  • Fever (30%)
  • Back pain (28%)
  • Sinus infection (28%)
  • Muscle spasms (27%)

Approximately 16% of patients discontinued DPd due to unacceptable side effects.

Watch videos on common DPd therapy side effects below

Side effect videos Side Effect Videos
AnemiaAnemiaFatigue Fatigue DiarrheaDiarrheaConstipationConstipationNausea and VomitingNausea and VomitingPainPain

Monitoring

How often is 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), common multiple myeloma labs, plus any others your doctor may order.

How often is imaging needed?

Imaging may be checked during treatment. Imaging may include: bone scans, computerized tomography (CT) scans, or magnetic resonance imaging (MRI).

How might blood test results/imaging affect treatment?

Depending upon the results, your doctor may advise to continue DPd as planned, or delay or switch therapy.

ChemoExperts Tips

What are the 10 most important things to know about DPd while receiving therapy?

  • Approximately 50% of patients experience an infusion reaction, which most commonly occur during the first dose of daratumumab (infusion reactions during subsequent doses are less likely). Acetaminophen (Tylenol®) and an antihistamine such as diphenhydramine (Benadryl®) will be given approximately one hour before each dose of daratumumab to decrease the chance of an infusion reaction
  • Because the first infusion of daratumumab takes a significant amount of time and because reactions are common during the first treatment, your doctor may choose to give the first dose over two days (Days 1 and 2 of Cycle 1) instead of one day (Day 1 only). This is called a “split dose” schedule and helps avoid very long days at the infusion center or the need to be treated in the hospital setting
  • On days daratumumab is given, your doctor may instruct you to take half of your dexamethasone dose (20 mg) before your infusion then 20 mg the day after the infusion
  • If you have an obstructive lung disorder such as COPD or emphysema, you may be instructed to use an inhaler after your infusion of daratumumab
  • Therapy with daratumumab can increase your risk of experiencing herpes zoster (shingles). You will be given an anti-viral medication such as acyclovir (Zovirax®) or valacyclovir (Valtrex®) to lessen your risk. These medications should be started within 1 week of starting treatment with daratumumab and taken until 3 months after therapy is stopped
  • Daratumumab interferes with testing that is done to determine what type of blood you can receive if you need a blood transfusion. This effect can last up to 6 months after completing therapy with daratumumab. Before your first infusion of daratumumab, you will have a type-and-screen performed to help determine what type of blood you can receive if you need it in the future. Inform your healthcare provider that you are taking daratumumab if any blood transfusion are planned
  • Daratumumab can affect the results of a test used to assess response to therapy called serum protein electrophoresis (SPEP). Addition testing may be needed to assess your response to therapy with daratumumab
  • Additional medications that may be prescribed include Bactrim® (Sulfamethoxazole/Trimethoprim) to prevent Pneumocystis Pneumonia and omeprazole (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 DPd (Daratumumab + Pomalidomide + 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 DPd (Daratumumab + Pomalidomide + Dexamethasone). Depending upon your income, they may be able to help cover the cost of:

  • Daratumumab
  • Pomalidomide
  • 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 DPd (Daratumumab + Pomalidomide + 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 DPd (Daratumumab + Pomalidomide + Dexamethasone)

Individual Drug Label Information

Daratumumab (Darzalex®)

  • Daratumumab is an intravenous infusion
  • Acetaminophen (Tylenol®), diphenhydramine (Benadryl®), and a corticosteroid such as methylprednisolone (Solu-Medrol®) will be given approximately one hour before each dose
  • A corticosteroid such as methylprednisolone (Solu-Medrol®) is taken on the first and second days after each infusion
  • An inhaler may been used after each treatment if you have an obstructive lung disorder such as COPD or emphysema
  • May increase your risk of experiencing herpes zoster (shingles). Acyclovir (Zovirax®) or valacyclovir (Valtrex®) may be taken to lessen your risk
  • Daratumumab interferes with testing that is done to determine what type of blood you can receive if you need a blood transfusion. Inform your healthcare provider that you are taking daratumumab if any blood transfusion are planned
  • Daratumumab can affect the results of a test used to assess response to therapy
  • Females who are of reproductive potential should use contraception during therapy and for at least 3 months after completing therapy
General Daratumumab (Darzalex) Side Effects
  • May cause fatigue
  • Can cause allergy symptoms such as a runny nose
  • Can cause an upper respiratory tract infection or a sinus infection Fever 
  • Diarrhea
  • Shortness of breath
  • Click on the daratumumab (Darzalex) package insert below for reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaFatigue Fatigue BleedingBleedingAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Pomalidomide (Pomalyst®)

  • Pomalidomide is an oral capsule available in 1 mg, 2 mg, 3 mg, and 4 mg strengths 
  • Can be taken on an empty stomach with a large glass of water. Do not eat two hours before and until two hours after taking a dose. Swallow capsule whole and do not break, open, or chew 
  • If you miss a dose, take it as soon as possible ONLY if it is within 12 hours since the dose should have been taken, then return to the normal schedule. If it is already been past 12 hours since the dose should have been taken, do not take the dose. Wait until your next dose is due 
  • Store at room temperature 
  • Dosage adjustments may be required for liver function, low platelets, or low white blood cells 
  • May interact with certain antifungal and seizure medications. Ask your doctor or pharmacist to review your medications for any possible interactions 
  • May interact with grapefruit and grapefruit juice causing increased blood levels of pomalidomide. This could increase your risk of experiencing side effects. Avoid eating grapefruit and drinking anything containing grapefruit juice during treatment 
  • Avoid therapy with St. Johns Wort as it will decrease blood levels of pomalidomide. This could decrease the effectiveness of pomalidomide 
  • Smoking while on therapy with pomalidomide may reduce its effectiveness. Talk to your doctor or pharmacist about smoking cession and available nicotine replacement therapies 
General Pomalidomide (Pomalyst) Side Effects 
  • Low white blood cells and platelets are common during therapy. Your dose of pomalidomide may need to be adjusted to held for a period of time 
  • Pomalidomide causes a higher chance of developing a blood clot, especially when used with dexamethasone. An “blood thinner” such as aspirin or warfarin may be used to decrease the risk of a clot forming 
  • Nerve pain in hands or feet may occur. Tell your doctor if you are experiencing these symptoms  
  • Although rare, pomalidomide may increase your risk of developing secondary cancers such as myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML)  
  • Click on the pomalidomide (Pomalyst) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue BleedingBleedingConstipationConstipationPainPainAnemiaAnemiaNeutropenic FeverNeutropenic FeverBlood ClotsBlood Clots

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) Chari A, Suvannasankha A, Fay JW, et al. Daratumumab plus pomalidomide and dexamethasone in relapsed and/or refractory multiple myeloma. Blood 2017;130:974-981

2) Barr H, Dempsey J, Waller A, et al. Ninety-minute daratumumab infusion is safe in multiple myeloma. Leukemia 2018;32:2495-2518

Created: March 19, 2020 Updated: March 19, 2020

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 Revised International staging system (R-ISS) for multiple myeloma. The type and effectiveness of the treatment may depend upon the stage and whether prior treatments have been tried.

What cell type does multiple myeloma come from and what does it look like?                                 Multiple myeloma commonly affects the following body parts: bone, blood, and kidneys

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.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is a teratogen?

A drug that is known to cause severe birth defects or fetal death. These drugs should NOT be used during pregnancy and patients should avoid becoming pregnant while taking these drugs.
  • Women, if taking a teratogenic medication, should abstain from heterosexual intercourse or use two forms of reliable contraception at least 4 weeks prior to, during, and for 4 weeks after treatment
  • Males (even after vasectomy), if taking a teratogenic medication, must use a latex or synthetic condom during any sexual contact with women of childbearing potential and must not donate sperm for up to 28 days following discontinuation of therapy.

Common DPd starting doses

  • Daratumumab 16 mg/kg intravenous infusion once weekly (Days 1, 8, 15, and 22) of cycles 1 and 2, then once every other week (Days 1 and 15) of cycles 3 through 6, then once monthly thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions
  • Pomalidomide 4 mg tablet by mouth daily for 21 days continuously on days 1 through 21, followed by 7 days break where pomalidomide is NOT taken (days 22 through 27)
  • Dexamethasone:
    • 40 mg (ten 4 mg tablets) by mouth once weekly (Days 1, 8, 15, and 22)
      OR
    • 20 mg (five 4 mg tablets) by mouth once weekly (Days 1, 8, 15, and 22)

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

​What labs are used to monitor multiple myeloma?

Commonly used labs to diagnose and monitor for treatment response in patients with multiple myeloma may include:

Serum Protein ElectroPhoresis (SPEP)
- Serum Immunofixation Electrophoresis (IFE)
- Lactate DeHydrogenase (LDH)
- Serum Free Light Chains (FLC)
- Quantitative immunoglobulins
- Beta 2-microglobulin (B2M)
- Cytogenetic analysis (karyotyping and FISH testing)

Note: Some labs may not apply. In addition, some labs are checked only at diagnosis, while others are used to assess response to treatment.