Treatment with selinexor (Xpovio) for relapsed or refractory multiple myeloma is moving toward lower, more tolerable dosing. “Less is often more,” focusing on keeping patients on therapy longer rather than using high doses that cause more side effects.
Instead of the older high-dose schedule of 80 mg twice weekly, doctors now favor a lower weekly dose of 60 to 80 mg combined with bortezomib and dexamethasone. Dr. Richter also recommends a 28-day cycle with one week off to reduce low platelet counts and bone marrow fatigue. Studies show that patients who reduced their dose early actually had better progression-free survival, suggesting that maintaining treatment over time is more important than pushing higher intensity.
In the BOSTON trial, the three-drug combination improved progression-free survival to 13.9 months compared with 9.5 months for standard two-drug therapy. Patients treated earlier in relapse did even better, with progression-free survival reaching 21 months after one prior therapy and 30 months in patients who had not previously received a proteasome inhibitor. Selinexor remains a useful option, especially for patients who are not eligible for CAR T therapy or who want to avoid the monitoring requirements of some newer treatments.