Over 89 year old female with kappa light chain multiple myeloma, diagnosis based on marrow involvement of 10-15% clonal population with light chain involved:uninvolved ratio >100, and biopsy proven amyloidosis in the bone marrow with suspected cardiac and nervous system involvement. Initial light chain levels 5 years ago at diagnosis were >9grams. Incredibly without treatment have come down to about 4g. Blood counts, electrolytes, and renal function have remained stable as well. She has never been interested in receiving therapies given her age and that she feels well overall. However, as she is having some progression of cardiac symptoms and fatigue, she would be willing to try therapies that are minimally toxic and do not require any time at an infusion center. Thoughts are towards oral cytoxan and dexamethasone. Are there other potential regiments that would be tolerated and helpful in her case?
Single agent daratumumab is extremely well tolerated in this patient population and has actually been studies in advanced cardiac amyloid (stage IIIB). Would give with extremely low doses of dex. Plus dara is subq so visits are quick. oral cy/dex is not likely to have significant effiacy. If she flat out refuses to come in for parenteral therapy you can conisder ixazomib/dex as rev/dex can be tough to tolerate in the setting of cardiac amyloidosis. Last thought is that amyloid tends to have a higher rate of t(11;14). did she have FISH? Although very far from first line therapy. Venetoclax/dex is very well tolerated but only effective in t(11;14)
