How to optimize outpatient delivery of bispecific antibody therapy for MM

The Multiple Myeloma Hub spoke with Rakesh Popat, UCL Hospitals NHS Foundation Trust, London, UK. We asked how to optimize outpatient delivery of bispecific antibody therapy for multiple myeloma (MM). 

In this interview, Popat discusses practical strategies to support the outpatient delivery of bispecific antibody therapy, including patient selection, caregiver support, and access to timely medical care if needed. Popat also outlines approaches that could facilitate step-up dosing in the outpatient setting, such as strategies to reduce the risk of cytokine release syndrome (CRS) and the potential use of wearable technology and remote monitoring.

Key points 

• Bispecific antibodies require close monitoring during the initial step-up phase because of the risk of CRS and neurological toxicities such as immune effector cell-associated neurotoxicity syndrome (ICANS).¹  
• Appropriate patient selection is important when considering step-up dosing in the outpatient setting.²  
• Patients should have access to a caregiver who is available 24 hours a day and ideally be able to reach the treating hospital within 60 minutes if medical assessment is required; comorbidities should be well controlled, and patients should be assessed for cognitive status, low tumor burden, and active infections.^1,2  
• Patients at high risk of clinical deterioration, including those with plasma cell leukemia or central nervous system involvement, may not be suitable, while those with a high disease burden require individualized assessment.^2,3 
• Close monitoring for CRS and ICANS, together with the ability to access prompt hospital assessment if symptoms develop, is important when considering step-up dosing in the outpatient setting.^1,2 
• Strategies to reduce the risk of CRS may help facilitate outpatient delivery. 
• Prophylactic tocilizumab before the first step-up dose can reduce the risk of CRS, while prophylactic dexamethasone may provide an alternative where tocilizumab cannot be administered.²  
• Wearable technology and remote monitoring are being explored as approaches to monitor vital signs and identify signs of CRS or clinical deterioration while patients remain outside the hospital.¹  
• Outpatient delivery may enable patients to remain at home or in nearby accommodation during treatment, while reducing reliance on inpatient care and increasing treatment capacity.²