Frail Transplant-Ineligible Myeloma — RACP Adult Medicine MCQ

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ModerateHaematologyFrail Transplant-Ineligible MyelomaRACP Adult Medicine

A 78-year-old frail woman with newly diagnosed myeloma (IgA lambda, ISS III) is not a transplant candidate. She has CKD stage 3b (eGFR 35), ECOG PS 2, and lives alone. What is the most appropriate first-line regimen?

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Correct answer: A — Lenalidomide/dexamethasone alone

For frail, transplant-ineligible patients, lenalidomide/dexamethasone (Rd) is a well-tolerated option. Daratumumab-Rd (DaraRd) per MAIA trial showed superior PFS and is preferred if feasible. VRd-lite (reduced intensity VRd) is an alternative. The choice depends on frailty assessment (IMWG frailty score), renal function, and patient preference. Lenalidomide dose must be adjusted for renal function (5 mg daily if eGFR <30). Bortezomib is preferred in renal impairment as it is not renally cleared.

Reference: NCCN – 2025 – Myeloma; MAIA Trial; ALLG 2024