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Lenalidomide (Revlimid®), a derivative of thalidomide, is the first oral drug that was developed as treatment for myeloma. It is an immumomodulatory drug (IMiD) and exerts multiple actions including anti-myeloma, anti-inflammatory and anti-angiogenic (inhibiting new blood vessel formation) activities.

Its use as a first line treatment is only allowed in Wales and Scotland, where it is accepted for restricted use in combination with dexamethasone for newly diagnosed transplant-ineligible patients who are intolerant or contraindicated to thalidomide.

Efficacy

Evidence for the safety and efficacy of Revlimid come from a number of Phase III trials, including the FIRST trial (MM-020) which showed that PFS was significantly longer in patients receiving continuous Revlimid and dexamethasone (25.5 months) compared to those receiving MPT (21.2 months). Median overall survival was 59 month versus 48 months respectively and patients in the Revlimid arm had a 25% reduction in the risk of death compared to patients in the MPT arm.

Administration

Lenalidomide is taken as a single oral dose. The dose can be altered if toxicity is significant and it is worth starting at a lower dose in older frailer patients. The dose needs adjusting in cases of renal impairment.

The RD treatment combination

 

RD regimen Type of drug Administration Schedule
Lenalidomide

 

 

Dexamethasone

 

 

 

Immunomodulatory drug

 

 

Steroid

 

 

 

 

 

Oral

 

 

Oral

 

 

 

 

 

 

28-day cycle

 

25 mg once daily for 21 consecutive days

 

40 mg once daily on days 1, 8, 15, 22

 

For patients ≥75 years of age, the starting dose of dexamethasone is 20 mg/day on days 1, 8, 15 and 22

Common side-effects of RD

The most common side effects of lenalidomide are fatigue, low neutrophils and platelets, increased thrombotic risk and diarrhoea.

Recent research has identified that lenalidomide-induced diarrhoea may be caused by bile acid malabsorption. Where appropriate, patients should be tested for bile acid malabsorption and started on bile acid sequestrant treatment e.g. colesevelam (Cholestagel®). This has been shown to improve symptoms and quality of life and allowed patients to continue with treatment long term.

 

Other information on Revlimid is described in more detail in the “Treatment at second relapse” section.

Further reading

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