Types of treatment

If you’re looking for information on a specific myeloma treatment, see our Learning hub where you will find a list of our treatment infosheets.

If you would like to read more about clinical trials, see our Clinical trials webpage.

Steroids (corticosteroids)

Steroids are medicines that are made to copy hormones that are naturally produced in the body. They are commonly used as part of myeloma treatment.

The steroids that are used in myeloma are known as glucocorticoids, and are different from the steroids used to build muscle. Glucocorticoids can change the body’s immune system responses, reduce inflammation, and cause myeloma cells to die. 

Steroids are also used to enhance the effects of other anti-myeloma treatment combinations. 

Sometimes, steroids can help to reduce symptoms such as nausea caused by chemotherapy, or hypersensitivity (allergic) reactions to certain medicines or blood products. 

Steroids can be given alone or in combination with chemotherapy or other anti-myeloma treatments. 

They can be taken as tablets or given into a vein through a drip (intravenously). The two most commonly used steroids in myeloma are dexamethasone and prednisolone.

Chemotherapy (chemo)

Chemotherapy, which is often called ‘chemo’ for short, is used alone or in combination with other medicines to kill cancer cells. 

The treatment works by disrupting the way that rapidly dividing cells, like myeloma cells, divide and reproduce. 

Chemotherapy can be used at different times along your myeloma treatment pathway, and can be taken orally as tablets or may be given by injection into the skin (subcutaneously) or into a vein through a drip (intravenously). It is usually given in ‘cycles’, which include a period of active treatment with a rest period in-between to allow healthy blood cells to recover. 

Chemotherapy medicines used for myeloma include melphalan and cyclophosphamide.

Radiotherapy (radiation therapy)

Radiotherapy is used in myeloma to treat some specific problems such as lesions and plasmacytomas, and to relieve pain. Not everyone with myeloma will need radiotherapy. 

Radiotherapy works by breaking the chain of myeloma cell replication. It damages the cell’s DNA, causing the cell to die.

If you need radiotherapy, a radiation oncologist will prescribe the type, dose and frequency of radiotherapy that is suitable for you. 

Immunomodulators (IMiDs)

Immunomodulators, or IMiDs, are medicines that work by modifying your immune system. They act in many different ways to treat myeloma, which include:

• directly killing or stopping the growth of myeloma cells 
• boosting the immune response against myeloma cells 
• altering the production of chemical messages involved in the growth and survival of myeloma cells 
• blocking the growth of new blood vessels that supply myeloma cells with oxygen and nutrition (this is called anti-angiogenesis) 
• preventing myeloma cells from sticking to the bone marrow. 

IMiDs are taken orally as tablets. Commonly used IMiDs are thalidomide (Thalomid®), lenalidomide (Revlimid®), and pomalidomide (Pomalyst®). Iberdomide and mezigdomide are two newer IMiDs in development.

Proteasome inhibitors (PIs)

Proteasomes are large molecules that are present in all cells in the body. They are involved in cell regulation and help to remove, breakdown and recycle damaged proteins.

Proteasome inhibitors, or PIs, work by temporarily blocking the action of proteasomes in cells, causing proteins to build up, and the myeloma cells to stop growing and die.

These medicines are taken orally as tablets or may be given by injection into the skin (subcutaneously) or into a vein through a drip (intravenously). The most commonly used PIs in myeloma include bortezomib (Velcade®), carfilzomib (Kyprolis®), and ixazomib (Ninlaro®).

Stem cell transplant (SCT)

There are two different types of stem cell transplant, autologous (where your own stem cells are used), and allogeneic (where donor stem cells are used). Both can be used as treatment options in myeloma, although autologous stem cell transplants are much more widely used.

High-dose therapy and autologous stem cell transplant (HDT-AuSCT) is a treatment option that usually follows initial therapy in people who are eligible for the treatment. HDT-AuSCT involves retrieving a person’s own stem cells using a process called apheresis. The stem cells are later reinfused to ‘rescue’ the bone marrow after high-dose chemotherapy. 

An allogeneic SCT involves using stem cells from a matched donor, who may or may not be a relative. The main advantage of allogeneic transplants is that they aim to use the immune system of the donor to help fight the myeloma cells and potentially prevent relapse.

However, the risk of this procedure is that the donor’s immune cells can also attack the recipient’s healthy cells, leading to graft-versus-host disease, which can be serious and potentially life-threatening. That’s why allogeneic transplants are only considered in a small number of people where it’s thought to be the most appropriate treatment option at that time.

Monoclonal antibodies (mAbs)

Monoclonal antibodies, or mAbs, are engineered in the laboratory to copy the process that our immune system usually uses to recognise and fight foreign substances. 

In myeloma, mAbs recognise and bind to proteins, called antigens, that are found in large amounts on the surface of myeloma cells and ‘flag’ these cells for your immune system to destroy them. Different types of mAbs target different antigens on myeloma cells.

mAbs are given as an injection into the skin (subcutaneously) or into a vein through a drip (intravenously). They are usually used in combination with other anti-myeloma treatments plus a steroid. 

The two mAbs currently used in myeloma treatment are daratumumab (Darzalex®) and elotuzumab (Empliciti®). Isatuximab and siltuximab are mAbs in development.

Bi-specific T-cell engagers (BiTE®s)

Bi-specific T-cell engagers, or BiTE®s, help the immune system recognise and kill cancer cells. They are designed to form a bridge between cancer cells and a type of immune cells (T cells), so the cancer cells are more likely to be killed by the immune system. 

These medicines are made up of two targeting proteins, called receptors. One receptor finds and locks onto antigens on the surface of cancer cells and the other receptor locks onto proteins on the surface of the T cells. 

BiTE®s are in their early stages of development. Products in development include teclistamab, elranatamab and cevostamab.

Selective inhibitors of nuclear exports (SINEs)

Selective inhibitors of nuclear exports, or SINEswork by blocking the action of a protein called exportin 1 (XPO1) in the centre of myeloma cells. Myeloma cells have a high level of XPO1. Blocking this protein’s actions allows genes that control tumour growth to be retained in the nucleus of the myeloma cells, leading to their controlled death. 

Selinexor (Xpovio®) is currently the only SINE used in the treatment of myeloma. It is taken orally as a tablet. 

BCL-2 inhibitor

BCL-2 is a protein that prevents programmed cell death and can be found in higher amounts in myeloma cells. 

BCL-2 inhibitor medicine inhibits the action of BCL-2, causing myeloma cells to die. This medicine works best in people who have a certain genetic abnormality called translocation of chromosomes 11 and 14 (t(11;14). 

Venetoclax (Venclaxta®) is the most well-studied BCL-2 inhibitor used in myeloma, and is currently being evaluated in clinical trials.

Chimeric antigen receptor T-cell therapy (CAR T-cell therapy)

CAR T-cell therapy is a once-only procedure that involves extracting, reprogramming, and reinfusing a person’s own immune cells to fight myeloma. 

In CAR T-cell therapy, a small amount of your T cells are collected and sent to a laboratory to be ‘retrained’ by adding genetic information to them so they are able to recognise, bind to and destroy cancer cells. You will be given bridging chemotherapy to control the myeloma while this process takes place. The CAR T-cells are then infused into a vein through a drip (intravenously). 

The genetic information added to the T-cell targets a specific antigen that is on the surface of cancer cells. In myeloma, the most common target is B-cell maturation antigen (BCMA). 

Other target antigens are also being researched. Two examples of CAR T-cell therapy are cilta-cel (Carvykti®) and ide-cel (Abecma®).

Antibody-drug conjugates (ADCs)

Antibody-drug conjugates, or ADCs, are made up of two different types of medicines that are linked together to treat myeloma. 

Belantamab mafodotin (Blenrep®), is a combination of a monoclonal antibody, belantamab, linked with the chemotherapy, mafodotin. It is given into a vein (intravenously). 

Belantamab, the monoclonal antibody part of the treatment, is engineered in the laboratory to find a receptor on the surface of myeloma cells called B-cell maturation antigen or BCMA. Belantamab attaches to BCMA, sending a signal to your immune system to recognise and kill the cells. 

Mafodotin, the chemotherapy part of this treatment, is very effective at killing myeloma cells and works better if it is guided to enter the myeloma cells by an antibody directed at myeloma. When it is given as part of the antibody molecule, the chemotherapy becomes active once it is guided to and enters the myeloma cells that have BCMA on the surface. When mafodotin enters the myeloma cells, it disrupts the skeleton of the cells and causes their death. 

This means that the myeloma cells are killed by both the immune system and chemotherapy.