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Treatment Name: VTd (Velcade® + Thalidomide + dexamethasone)

VTd (Velcade® + Thalidomide + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM)

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

V - Velcade® (Bortezomib)
T - Thalidomide (Thalomid®)
d - dexamethasone (Deltasone, dex)

Goals of therapy:
VTd is given to decrease symptoms and slow the progression of multiple myeloma, not to cure this disease. After treatment, patients who respond to VTd typically are monitored, continue with maintenance therapy, or proceed to bone marrow transplant.

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Schedule

  • Bortezomib (Velcade) subcutaneous injection (SubQ) on Days 1, 4, 8, and 11
  • Thalidomide 50 mg to 100 mg by mouth daily for 21 days continuously on Days 1 - 21
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, then 4, 5, then 8, 9, then 11, 12
         OR
    40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4, then 9, 10, 11, 12
         OR
    40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4, then 9, 10, 11, 12 during Cycles 1 and 2
         -then, 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4 during Cycles 3 and 4

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

VTd is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to four times, until the regimen stops working, or unacceptable toxicity is experienced.

Thalidomide requires registration with the REMS program EVERY month before a new prescription can be dispensed.

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 VTd are shown here. Side effects sometimes have percentage ranges [example: 14 – 34% have nerve pain] because they differed between clinical studies:

On average, 4 - 7% of patients discontinue VTd due to unacceptable side effects.

Side effect videos Side Effect Videos
ConstipationConstipationBlood ClotsBlood ClotsPainPainNeutropenic FeverNeutropenic Fever

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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), serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), 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, 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.

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ChemoExperts Tips

  • Thalidomide is a teratogen. Excercise extreme caution when handling and storing this medication
  • Bortezomib 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) 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 VTd (Velcade® + Thalidomide + 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 VTd (Velcade® + Thalidomide + dexamethasone). Depending upon your income, they may be able to help cover the cost of:

  • Velcade®
  • Thalidomide
  • 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 VTd (Velcade® + Thalidomide + 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 VTd (Velcade® + Thalidomide + dexamethasone)

Individual Drug Label Information

Velcade® (Bortezomib)

  • Velcade can be given either as an intravenous (I.V.) infusion, but is more commonly administered 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 Velcade (Bortezomib) 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 Velcade (bortezomib) package insert below for reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaFatigue Fatigue BleedingBleedingConstipationConstipationPainPain

See DailyMed package insert.

Thalidomide (Thalomid)

  • Thalidomide is an oral capsule available in 50 mg, 100 mg, 150 mg, and 200 mg 
  • Thalidomide is a human teratogen. In order to decrease the risk of embryo-fetal exposure, thalidomide is available only through a restricted distribution program (Thalomid REMS)  
  • Thalidomide can be taken with or without food with a large glass of water. It is best to take thalidomide at night due to possible drowsiness. Swallow capsule whole and do not break, open, or chew 
  • If you miss a dose, take the dose 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 
  • Thalidomide should be stored at room temperature 
  • Dosage adjustments may be required for low white blood cells or nerve pain 
General Thalidomide (Thalomid) Side Effects 
  • Low white blood cells are common during therapy. Your dose of thalidomide may need to be adjusted to held for a period of time 
  • Commonly causes tingling in fingers and toes and nerve pain, which may become permanent if not addressed. Tell your doctor if you are experiencing these symptoms 
  • May cause drowsiness. Take thalidomide at night and avoid taking with alcohol 
  • May cause constipation; preventative medicines may help decrease or avoid constipation 
  • Thalidomide 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 
  • Although rare, thalidomide may increase your risk of developing secondary cancers such as myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML)  
  • Click on the thalidomide (Thalomid) package insert below for reported side effects and possible drug interactions

Side Effect Videos
ConstipationConstipationPainPainNeutropenic 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. Cavo M, Tacchetti P, Patirarca F, et al. Bortezomib with thalidomide plus dexamethasone compared with thalidomide plus dexamethasone as induction therapy before, and consolidation therapy after, double autologous stem-cell transplantation in newly diagnosed multiple myeloma: a randomised phase 3 study. Lancet. 2010;376:2075–2085.

2. Rosinol L, Oriol A, Teruel AI, et al. Superiority of bortezomib, thalidomide, and dexamethasone (VTD) as induction pretransplantation therapy in multiple myeloma: a randomized phase 3 PETHEMA/GEM study. Blood. 2012;120:1589-1596.

Created: September 5, 2015 Updated: September 10, 2018

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.

Common Starting Doses

  • Bortezomib 1.3 mg/m2 SubQ on Days 1, 4, 8, and 11
  • Thalidomide 50 - 100 mg by mouth daily for 21 days continuously on Days 1 - 21
  • Dexamethasone 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 4, 5, 8, 9, 11, 12
        OR
    40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4, then 9, 10, 11, 12
        OR
    40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4,  then 9, 10, 11, 12 during Cycles 1 and 2
    • Then, 40 mg (ten 4 mg tablets) by mouth on Days 1, 2, 3, 4 during Cycles 3 and 4

Clinical Studies

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

1. Cavo M, Tacchetti P, Patirarca F, et al. Bortezomib with thalidomide plus dexamethasone compared with thalidomide plus dexamethasone as induction therapy before, and consolidation therapy after, double autologous stem-cell transplantation in newly diagnosed multiple myeloma: a randomised phase 3 study. Lancet. 2010; 376:2075–2085.

2. Rosinol L, Oriol A, Teruel AI, et al. Superiority of bortezomib, thalidomide, and dexamethasone (VTD) as induction pretransplantation therapy in multiple myeloma: a randomized phase 3 PETHEMA/GEM study. Blood. 2012;120:1589-1596.

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 Thalidomide 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 thalidomide and will have pregnancy tests performed periodically throughout treatment. Thalidomide 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 thalidomide 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 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 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.