VRd = Bortezomib + Lenalidomide + Dexamethasone
- Type: Standard triplet induction regimen for newly diagnosed multiple myeloma (both transplant-eligible and transplant-ineligible).
Components & Mechanisms:
- Bortezomib (Velcade®) – Proteasome inhibitor
- Inhibits 26S proteasome, causing accumulation of proteins → apoptosis.
- IV or SC dosing.
- Lenalidomide (Revlimid®) – Immunomodulatory drug (IMiD)
- Binds cereblon, leading to degradation of Ikaros/Aiolos → apoptosis + immune activation.
- Oral agent.
- Dexamethasone – Corticosteroid
- Direct anti-myeloma effect + reduces inflammation and infusion reactions.
Typical Dosing (Induction, 21-day cycle):
- Bortezomib: 1.3 mg/m² SC (preferred) or IV, Days 1, 4, 8, 11.
- Lenalidomide: 25 mg PO daily, Days 1–14.
- Dexamethasone: 40 mg PO or IV weekly (may be split into 20 mg for tolerability, esp. in older pts).
Cycles usually repeated × 4 (transplant-eligible), or until progression/tolerability (transplant-ineligible).
Key Toxicities & Pharmacist Notes:
- Bortezomib: Peripheral neuropathy (↓ risk with SC route), thrombocytopenia, herpes zoster reactivation → acyclovir prophylaxis required.
- Lenalidomide: Neutropenia, anemia, thrombocytopenia, VTE risk, rash → requires REMS, anticoagulation prophylaxis.
- Dexamethasone: Hyperglycemia, mood changes, immunosuppression, insomnia.
Monitoring:
- CBC, renal function, electrolytes.
- Signs of neuropathy, thrombosis, infection.
- VTE prophylaxis (aspirin vs anticoagulant depending on risk).
- Antiviral prophylaxis (acyclovir/valacyclovir).
High-yield takeaways:
- VRd = frontline standard of care in MM.
- Route matters: SC bortezomib preferred to reduce neuropathy.
- Supportive care required: VTE prophylaxis + antiviral prophylaxis.
- Commonly followed by stem cell transplant (eligible patients) or continued until progression.