DR FONSECA: The dara infusions, they really are a challenge only for the first infusion. And I think one cannot talk enough about the importance of the practicalities. One has to plan for the full day. The patients do start getting the infusion, and it’s the same logistics as you have with rituximab. Most of the time, their reactions are upper respiratory. So it could be tightness, nasal congestion, some coughing. I don’t think I have had a single patient where we cannot give the daratumumab because of the reactions, which is something you sometimes face with the rituximab. There are patients who simply cannot get it.

DR LOVE: What about time to infusion? What is the longest it’s taken you to get the first dose in?

DR FONSECA: The first day, we plan for 12 hours in the clinic. The patients get premedications at home. They get premeds when they arrive at the center. And we have the luxury that we have a place where it can go for longer. So usually we can complete it within that time frame.

For a busy oncology practice in the community, I always say there’re 2 things that people are doing. One is they’re splitting doses. But probably the most important one is just give as much as you can on day 1, and you’re going to flush some of that reaction. So by the time you get to the second week, and it’s true with most of the monoclonals, then you tend not to have reactions. So it’s just day 1 that needs to be managed.

DR LOVE: What do you think about splitting it into 2 days?

DR FONSECA: We haven’t done that. It would make sense, just because it’s a monoclonal. It’s going to be around in the body for a while. I would prefer to give it all together on day 1, if at all possible. But I wouldn’t make the logistics being a limitation so that patients don’t get daratumumab.

DR LOVE: Not every infusion center is open for 12.

DR FONSECA: Correct.

DR LOVE: What actually happened with him in the first infusion?

DR FONSECA: He did very well. We had the usual phone calls. And the phone calls have gone down over time. When we started using daratumumab we used to get like 5 phone calls between the morning and lunchtime. Now it’s rare that we get the phone calls because the nurses know perfectly well what to do. If we get a phone call, we pay more attention because that means it’s probably something more intense. But the nurses just manage very well now.

DR LOVE: And how long did it take to get that first day in?

DR FONSECA: It was about 8 hours for this particular patient.

DR LOVE: Interesting. And then, with successive treatments, what did it come down to?

DR FONSECA: Most of the patients we can do in 3 to 4 hours. They get their infusion, and there’s still the interference. They have to be at the center. It takes pretty much the full day because by the time you park, you get your IV and then you’re in lunchtime, it’s hard to do other things. But I think it’s quite more tolerable for patients.

DR LOVE: Noopur, any thoughts about this man’s case and the choice that Rafael made to use pomalidomide/daratumumab?

DR RAJE: It was obviously an interesting choice. The good news with Rafael’s patient — Rafael, your patient is a very IMiD-sensitive patient. You asked a question of would you add elo? This would be the place where I would absolutely think about adding elo, because, as of right now, elotuzumab, it’s a tough drug to fit into where we are in the relapsed/refractory setting because of the lack of single-agent activity. And it only partners well with an IMiD. So that’s something which I would certainly have thought about.

I agree with you when you talk about combining daratumumab with the IMiD versus with the proteasome inhibitor. The IMiD combination data looks absolutely stunning. If you look at the POLLUX data, which was presented at EHA, the hazard ratios, you’re right, were both similar for CASTOR as well as POLLUX. But the progression-free survival when you used lenalidomide with daratumumab was in the 80% range at about 2 years. And even the control arm did as well as an Rd arm does, which is a PFS of about 18 months or so.

With the bortezomib, we did see patients who were responding. When you add bortezomib with the daratumumab, you see the median PFS is not yet reached. It’s much lower. It’s about 55%-60%, so certainly lower than lenalidomide. In practice, the daratumumab in combination with pomalidomide has not yet been studied formally. It’s not an approved combination.

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