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Treatment Name: ERd (Elotuzumab (Empliciti®) + Revlimid® + dexamethasone)

ERd (Elotuzumab (Empliciti®) + Revlimid® + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM)

How does ERd work?
Each of the medications in the ERd chemo regimen are designed to kill or slow the growth of multiple myeloma cells. ERd may also work to enhance your immune system to help kill myeloma cells.

E – Elotuzumab (Empliciti®)
R – Revlimid® (lenalidomide)
d – Dexamethasone (Decadron®)

Alternative names: ELd, Elo-Rev-dex, Elo-Len-dex

Goals of therapy:
ERd is not given to cure multiple myeloma, but it may slow the progression of myeloma and decrease symptoms from the disease.

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Schedule

Cycles 1 and 2:

  • Pre-medications: acetaminophen, ranitidine, diphenhydramine all given 30 to 90 minutes before elotuzumab (Empliciti)
  • Elotuzumab intravenous (I.V.) infusion on Days 1, 8, 15, and 22 ฀
  • Lenalidomide 25 mg capsule by mouth daily for 21 days continuously, on Days 1 through 21 ฀
  • Dexamethasone (Dex): 
    • On days with elotuzumab I.V.: Dex 28 mg (seven 4 mg tablets) by mouth on Days 1 and 15, PLUS Dex 8 mg I.V. on Days 1 and 15
    • On days without elotuzumab I.V.: Dex 40 mg (ten 4 mg tablets) by mouth on Days 8 and 22
    • Take Dex between 3 and 24 hours before elotuzumab I.V. infusion

Cycles 3 and on:

  • Elotuzumab I.V. infusion on Days 1 and 15 ฀
  • Lenalidomide 25 mg capsule by mouth daily for 21 days continuously, on Days 1 through 21 ฀
  • Dexamethasone (Dex): 
    • On days with elotuzumab I.V.: Dex 28 mg (seven 4 mg tablets) by mouth on Days 1 and 15, PLUS Dex 8 mg I.V. on Days 1 and 15
    • On days without elotuzumab I.V.: Dex 40 mg (ten 4 mg tablets) by mouth on Days 8 and 22
    • Take Dex between 3 and 24 hours before elotuzumab I.V. infusion

Estimated total infusion time for this treatment:

Up to 4 hours for Cycle 1, Day 1 because of the possibility of experiencing infusion reactions with elotuzumab; as short as two hours for the remaining treatment days if elotuzumab is well tolerated.

Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time.

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

The elotuzumab portion of the ERd regimen is usually given in an outpatient infusion center, allowing the person to go home afterwards. It 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 ERd 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 of ERd are shown here: 

  • Low red blood cells [anemia] (96%)
  • Low platelets [thrombocytopenia] (84%)
  • Low white blood cells [neutropenia] (82%)
  • Fatigue (47%)
  • Diarrhea (47%)
  • Fever (37%)
  • Constipation (36%)
  • Cough (31%)
  • Muscle spasm (30%)
  • Back pain (28%)
  • Fluid accumulation in arms or legs (26%)
  • Sore throat or sinus infection (25%)
  • Trouble sleeping (23%)

Infusion reactions due to elotuzumab such as fevers, chills, and high blood pressure occur in approximately 10% of patients. These infusion reactions are typically not severe, occur most commonly during the first infusion, and often resolve within 25 minutes (range 5 to 70 min) when the infusion is stopped temporarily.

On average, 9% of patients discontinue treatment due to unacceptable side effects.

Side effect videos Side Effect Videos
AnemiaAnemiaFatigue Fatigue DiarrheaDiarrheaConstipationConstipationPainPain

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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 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/imaging affect treatment?
Depending upon the results, your doctor may advise to continue ERd as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

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ChemoExperts Tips

  • Premedications such as diphenhydramine (Benadryl®), ranitidine (Zantac®) or famotidine (Pepcid®), acetaminophen (Tylenol®), and dexamethasone (Decadron®) may be given before I.V. elotuzumab to help avoid infusion related reactions. A dose of I.V. dexamethasone is given in addition to the oral dose taken at home
  • A dosage reduction in lenalidomide (Revlimid®) may be required in certain individuals to help decrease side effects
  • A medication to prevent blood clots is usually recommended for patients receiving ERd. The exact medicine used may differ from patient to patient and will be chosen by your doctor
  • 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
  • Treatment with ERd may increase your risk of developing a secondary cancer including leukemia, lymphoma, and various types of solid tumors
  • 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 ERd (Elotuzumab (Empliciti®) + Revlimid® + 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 ERd (Elotuzumab (Empliciti®) + Revlimid® + dexamethasone). Depending upon your income, they may be able to help cover the cost of:

  • Elotuzumab
  • Revlimid®
  • 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 ERd (Elotuzumab (Empliciti®) + Revlimid® + 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 ERd (Elotuzumab (Empliciti®) + Revlimid® + dexamethasone)

Individual Drug Label Information

Elotuzumab (Empliciti®)

  • https://www.chemoexperts.com/fatigue.htmlhttps://www.chemoexperts.com/fatigue.htmlIs an intravenous infusion 
  • Premedications such as diphenhydramine, ranitidine or famotidine, acetaminophen, and dexamethasone may be given to help avoid infusion related reactions 
  • May interfere with commonly used multiple myeloma blood tests such as serum protein electrophoresis (SPEP) and immunofixation (IFE) that help determine response to therapy
  • Second primary malignancies (other cancers) can develop 
  • Elotuzumab has not been studied during pregnancy and breast feeding; however, it is commonly given with lenalidomide (Revlimid®) which can cause significant fetal harm
General side effects from elotuzumab (Empliciti®)
  • Infusion reactions 
  • Infections 
  • Liver injury  
  • Low blood counts of red cells, white cells, and platelets 
  • Nerve pain (neuropathy) 
  • Fever 
  • Fatigue 
  • Constipation and/or diarrhea 
  • Cough, sore throat, and upper respiratory tract infection 
  • Lung infection (pneumonia) 
  • Muscle spasms 
  • Back pain 
  • Headache 
  • Fluid build-up (swelling) in arms and legs 
  • Vomiting 
  • Trouble sleeping (insomnia) 
  • Click on the elotuzumab (Empliciti®) "See DailyMed package insert" web link for more reported side effects, possible drug interactions, and other elotuzumab prescribing information 

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue ConstipationConstipationPainPainAnemiaAnemia

See DailyMed package insert.

Revlimid® (Lenalidomide)

  • Revlimid ​Is a capsule
  • Is not to be used during pregnancy; it may cause human embryo toxicity and birth defects. Females must avoid pregnancy while taking this and for 4 weeks after finishing therapy 
  • Is only available through the R.E.M.S. program, which is Risk Evaluation and Mitigation Strategy http://www.accessdata.fda.gov/scripts/cder/rems/index.cfm 
  • Women should not breast feed while on this drug
  • Can cause severe low white blood cells and platelet cell counts. Patients who have “del 5q myelodysplastic syndromes” should have complete blood counts (CBC) monitored every week for the first eight weeks of treatment
  • Patients may require dose decreases and periodic stopping of doses for low blood cell counts, poor kidney function, or other reasons
  • Some patients may require growth factors to help stimulate blood cell production
  • Patients are at increased risk of blood clots in limbs (DVT- deep vein thrombosis) or lungs (PE- pulmonary embolism), as well as risk for heart attack and stroke.  A "blood thinner" such as aspirin or warfarin may be prescribed to decrease risk of clots
  • Is swallowed whole with or without food and with a large glass of water; take at the same time every day
  • If you miss a dose and it’s less than 12 hours late, take the dose.  If it’s more than 12 hours late skip the dose.  Do not take two doses at the same time
  • This capsule contains lactose.  Patients should advise their physician if they are lactose intolerant
  • Do not open capsules.  If powder from capsule touches skin, wash immediately with soap and water
  • Should be stored at controlled room temperature
  • May interact with digoxin, estrogen containing therapies, and erythropoietin
  • Has been linked to the development of other cancers in a small number of people
  • Do not donate blood during therapy and for one one month after completion of therapy
General Revlimid (Lenalidomide) side effects
  • Low while blood cells
  • Low platelet cells
  • Blood clots
  • Bleeding
  • Diarrhea
  • Constipation
  • Itching
  • Cough or shortness of breath
  • Skin rash
  • Pain
  • Nausea
  • Fatigue, dizziness
  • Muscle cramps
  • Low red blood cells
  • Swelling of arms and legs
  • Liver toxicity
  • Allergic reactions
  • Tumor Lysis Syndrome (TLS)
  • Click on the Revlimid (lenalidomide) package insert below for reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaFatigue 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

Lonial S, Dimopoulos M, Palumbo A, et al. Elotuzumab Therapy for Relapsed or Refractory Multiple Myeloma. N Engl J Med 2015;373(7):621-31.

Created: November 21, 2017 Updated: November 21, 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.

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.

What is the Revlimid REMS program?

REMS stands for Risk Evaluation and Mitigation Strategy. This program requires that all patients must sign a Patient-Physician agreement form acknowledging pregnancy risks before starting treatment. If you are female who can get pregnant, you must have 2 negative pregnancy tests before starting Revlimid® and will have pregnancy tests performed periodically throughout treatment. Revlimid® is only dispensed from certain pharmacies and the pharmacy will contact you before every prescription is dispensed. A confidential survey must also be taken every month before Revlimid® can be dispensed.

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 status, 2) 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

Common Starting Doses

Cycles 1 and 2:

  • Elotuzumab 10 mg/kg intravenous (I.V.) infusion on Days 1, 8, 15, and 22
  • Lenalidomide 25 mg capsule by mouth daily for 21 days continuously, on Days 1 through 21 ฀
  • Dexamethasone (Dex):
    • On days with elotuzumab I.V.: Dex 28 mg (seven 4 mg tablets) by mouth on Days 1 and 15, PLUS Dex 8 mg I.V. on Days 1 and 15
    • On days without elotuzumab: Dex 40 mg (ten 4 mg tablets) by mouth on Days 8 and 22

Cycles 3 and on:

  • Elotuzumab 10 mg/kg I.V. infusion on Days 1 and 15 only (no Elotuzumab on Days 8 or 22)
  • Lenalidomide 25 mg capsule by mouth daily for 21 days continuously on Days 1 through 21 ฀
  • Dexamethasone (Dex):
    • On days with elotuzumab I.V.: Dex 28 mg (seven 4 mg tablets) by mouth on Days 1 and 15, PLUS Dex 8 mg I.V. on Days 1 and 15
    • On days without elotuzumab I.V.: Dex 40 mg (ten 4 mg tablets) by mouth on Days 8 and 22

Cycle length is 28 days (four weeks).

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