NSP-01: Update to Nursing Care Pathway for Infection risk and Prophylaxis in RRMM receiving novel therapy

Introduction: New BCMA-targeted drugs have been FDA approved for relapsed and refractory multiple myeloma (RRMM). These new treatments provide excellent responses but also have side effects of prolonged neutropenia and increased risk for infection. Pneumocystis jirovecii pneumonia (PJP) fungal infection can cause life-threatening pneumonia in MM. Similarly, cytomegalovirus (CMV) is now more commonly seen in RRMM. In 2022, nurses at the Huntsman Cancer Institute (HCI) developed a nursing care pathway for monitoring PJP risk in patients receiving stem cell transplants, Chimeric antigen receptor T-cell (CarT) therapy, and bispecific antibodies (BsABs). Herein we present our experience after updating the nursing care pathway to reflect new recommendations and real-world exposures.

Methods: A rolling report of MM patients post-autologous transplant, post-CarT, or receiving BsABs was updated to include patient information for monitoring (including CD4 count, CMV NAAT, prophylaxis, and next lab appointment). Based on the report, nurses either (1) begin monitoring CD4 and/or CMV, (2) discontinue monitoring CD4 and/or CMV, (3) begin PJP prophylaxis (CD4 < 200), or (4) discontinue PJP prophylaxis (CD4 >200 for two consecutive months). Monitoring BsAbs patients for CMV via NAAT titers was added to the report and algorithm in October 2022. If CMV NAAT is detected but not quantifiable, weekly monitoring is performed until undetected. If CMV titer is quantifiable at >100 IU/mL, appropriate induction treatment is initiated with weekly monitoring. Therapy is continued until CMV NAAT is undetected or until 14 days. If a patient on CMV treatment has no clinical symptoms, therapy is discontinued once CMV NAAT is undetectable. Monthly monitoring of these patients continues. If CMV turns positive and the patient is symptomatic, an ID consult is initiated to streamline intervention(s).

Results: After closer monitoring of high-risk patients for a year, HCI has had no new PJP infections. Of the patients meeting the need for CMV viral load monitoring per algorithm, twelve are on bispecific therapy and two are post-CarT and received >1 dose of tocilizumab or dexamethasone (≥ 10 mg for 3 days) with baseline CMV IgG seropositivity. Only 14% (1 out of 14) required induction treatment, and remains on maintenance therapy for ongoing CMV viremia. This asymptomatic patient was on a BsAB clinical trial; the other patients being surveilled did not cross the treatment threshold.

Conclusions: Given the evolution of safety data and monitoring for novel treatments in RRMM, we updated our algorithm. As a result, nursing practice has elevated to quickly identifying patients at highest risk for developing PJP and CMV viremia and intervening appropriately. Prolonged treatment holds have been reduced due to this algorithm as evidenced by no new PJP infections and a small proportion of patients with mild CMV. In the future, we hope to refine best practices for CD4 and CMV titer monitoring and frequency in RRMM.