How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?  

After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and ...

Typically, we would use a continuous 3-drug regimen for high risk patients granted they are tolerating therapy without side effects. In standard risk patients, we would go to a maintenance approach once response has plateaued for a couple of cycles. 

I use 2-drug maintenance (generally lenalidomide 10mg daily, continuous, with bortezomib 1.3mg/m2 SC every other week) in high-risk myeloma. I use lenalidomide 10mg daily for standard-risk myeloma, and bortezomib SC every other week for t(4;14). Treatment is always adjusted based on response and tol...