Inside the Clinic: The Step-Up Strategy in talquetamab Therapy
Panelists discuss how the step-up dosing strategy for talquetamab involves graduated dose escalation from 0.01 to 0.06 mg/kg before reaching therapeutic levels to minimize severe cytokine release syndrome, with real-world data showing 85% to 86% of patients can safely receive outpatient step-up dosing, though one patient’s inpatient experience was chosen due to her drug allergies and travel distance considerations.
EP: 1.Karen's Story: Navigating Multiple Myeloma Treatment Lines
EP: 2.Understanding Bispecific Mechanisms and Dual Targeting in Multiple Myeloma: Why talquetamab for This Patient Journey
EP: 3.talquetamab Clinical Evidence: MONUMENTAL-1 to Real-World Data
EP: 4.Between Real-World Decisions: Selecting GPRC5D vs BCMA-Targeting Bispecific
EP: 5.Inside the Clinic: The Step-Up Strategy in talquetamab Therapy
EP: 6.Comprehensive Care: Essential Supportive Care Strategies for GPRC5D Bispecifics
Step-Up Dosing Strategy and Clinical Approach
Talquetamab therapy employs a carefully structured step-up dosing strategy to minimize severe cytokine release syndrome (CRS) risks while allowing the immune system to adapt gradually. The treatment begins with a priming dose of 0.01 mg/kg, followed by 0.06 mg/kg, before reaching the full therapeutic dose. This graduated approach, combined with subcutaneous administration, provides more controlled absorption compared to intravenous bispecific antibodies. Recent real-world data from Mayo Clinic presented at the European Hematology Association meeting demonstrates that outpatient step-up dosing is both feasible and safe, with 85% to 86% of 28 patients successfully starting treatment as outpatients and requiring minimal hospitalization averaging only 2.1 days total length of stay.
Individualized Treatment Setting Decision
Karen's step-up dosing was conducted as an inpatient due to specific clinical considerations rather than standard protocol requirements. Her decision was influenced by multiple drug allergies, including penicillin and certain pain medications, creating uncertainty about potential allergic reactions to the new therapy. Additionally, the practical challenge of making daily round trips of 3 hours each way made inpatient administration more feasible. Karen had previously utilized patient housing at the treatment center during her transplant procedures, demonstrating familiarity with extended stays for medical care. The inpatient setting proved beneficial when she experienced significant allergic reactions during initial dosing.
Initial Treatment Reactions and Long-term Management
During the step-up period, Karen experienced severe respiratory distress as her primary CRS manifestation, requiring immediate intervention with epinephrine and oxygen support. These reactions resolved quickly with tocilizumab treatment and did not recur in subsequent doses. However, Karen later developed a serious respiratory infection (viral pneumonia and respiratory syncytial virus) while traveling, which led to a chronic lung infection causing persistent cough and phlegm production. This ongoing respiratory issue requires intermittent antibiotic treatment but represents a separate complication rather than a direct treatment-related adverse effect.
