OpenOnco · Treatment Plan

Treatment plan — Multiple Myeloma

PLAN-VERIFIED-MM-L3-MM_3L_ISA_KD-V1 · v1 · 2026-07-15

Patient

VERIFIED-MM-L3-MM_3L_ISA_KD · Algorithm: ALGO-MM-3L

DiagnosisMultiple Myeloma

MOH / ICD-10C90.0

ICD-O-39732/3; C42.1

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-MM-3L-ISA-KD

Regimen

Isatuximab + Carfilzomib + Dexamethasone (Isa-Kd), 28-day cycles

Drugs + NSZU

Isatuximab (DRUG-ISATUXIMAB) 10 mg/kg IV · Days 1, 8, 15, 22 (cycle 1); days 1, 15 (cycles 2+) · IV ✗ Not registered in UA
Carfilzomib (DRUG-CARFILZOMIB) 20 mg/m² IV days 1-2 cycle 1 (ramp-up), then 56 mg/m² IV · Days 1, 2, 8, 9, 15, 16 of each 28-day cycle (56 mg/m² from day 8 cycle 1) · IV ⚠ NSZU — not for this indication
Dexamethasone (DRUG-DEXAMETHASONE) 20 mg IV or PO · Days 1, 2, 8, 9, 15, 16, 22, 23 of each 28-day cycle · IV ✓ NSZU covered

Supportive care

SUP-HSV-PROPHYLAXIS, SUP-PJP-PROPHYLAXIS, SUP-MM-VTE-PROPHYLAXIS, SUP-MM-BONE-PROTECTION

Reason

Primary current-line option selected by ALGO-MM-3L at step 3.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-MM-4L-TECLISTAMAB

Regimen

Teclistamab BCMA × CD3 bispecific (with step-up dosing) — continuous SC weekly

Drugs + NSZU

Teclistamab (DRUG-TECLISTAMAB) Step-up: 0.06 mg/kg SC day 1, 0.3 mg/kg SC day 4, 1.5 mg/kg SC day 7 (≥48h between doses, inpatient observation). Full dose 1.5 mg/kg SC weekly thereafter. · Weekly SC continuous (after step-up); transition to q2-weekly after ≥6 mo sustained ≥VGPR (per protocol amendment) · SC ✗ Not registered in UA

Supportive care

SUP-PJP-PROPHYLAXIS, SUP-HSV-PROPHYLAXIS, SUP-IVIG-HYPOGAMMA

Hard contraindications

CI-ACTIVE-INFECTION-FOR-ALEMTUZUMAB

Reason

Current-line alternative presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-BM-ASPIRATE	Bone Marrow Aspirate	Critical	histology	—	all tracks
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-FISH-PANEL	FISH (Fluorescence In Situ Hybridization)	Critical	genomic	CSD Lab ✓ (code TBC)	all tracks
TEST-FREE-LIGHT-CHAINS	Serum Free Light Chains	Critical	lab	—	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HCV-ANTIBODY	HCV Antibody	Critical	lab	—	aggressive
TEST-HIV-SEROLOGY	HIV Antibody/Antigen	Critical	lab	—	aggressive
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	aggressive
TEST-SPEP-UPEP	SPEP / UPEP with IFE	Critical	lab	—	all tracks
TEST-WHOLE-BODY-MRI	Whole-Body MRI	Critical	imaging	—	desired (aggressive, standard)
TEST-B2-MICROGLOBULIN	Beta-2 Microglobulin	Standard	lab	—	all tracks
TEST-CMV-SEROLOGY	CMV IgG/IgM	Standard	lab	—	aggressive
TEST-DAT-COOMBS	Direct Antiglobulin Test	Standard	lab	—	standard
TEST-ECHO	Echocardiography	Standard	imaging	—	all tracks
TEST-IMMUNOGLOBULINS	Quantitative Immunoglobulins	Standard	lab	—	all tracks
TEST-EBV-SEROLOGY	EBV Antibody Panel	Desired	lab	—	aggressive

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Multiple myeloma high-risk cytogenetics: any of t(4;14), t(14;16), t(14;20), del(17p)/TP53 loss, gain or amplification of 1q21 by interphase FISH on CD138-enriched plasma cells
Primary determinant for selecting quadruplet (D-VRd) over triplet (VRd) in transplant-eligible newly-diagnosed MM. R2-ISS captures most of these abnormalities; gain 1q21 is graded by copy count (≥4 copies = amp1q carries higher risk than…
RF-MM-HIGH-RISK-CYTOGENETICSSRC-NCCN-MM-2025SRC-ESMO-MM-2023
Multiple myeloma with significant renal dysfunction: CrCl <60 mL/min or serum creatinine >177 µmol/L (>2 mg/dL) attributable to myeloma kidney
Direction "investigate" — triggers lenalidomide dose adjustment in BOTH VRd and D-VRd and demands further workup (24-hr urine, kidney biopsy in selected cases) to distinguish myeloma kidney from other causes. Does not shift the…
RF-MM-RENAL-DYSFUNCTIONSRC-NCCN-MM-2025SRC-ESMO-MM-2023

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Alemtuzumab causes profound, prolonged CD4+ T-cell depletion (median recovery 9-12 months). Active uncontrolled infection at baseline becomes life-threatening once cellular immunity collapses. HIV-positive status is itself an absolute contraindication — alemtuzumab on top of HIV immunosuppression has unacceptable infectious mortality. CI-ACTIVE-INFECTION-FOR-ALEMTUZUMAB

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-MM-3L-ISA-KD)

Do not use with prior carfilzomib exposure — IKEMA enrolled carfilzomib-naive patients; efficacy and safety on re-challenge not established by this trial.
Do not use in ECOG PS ≥3 — patients with poor performance status were excluded from IKEMA; response and toxicity unpredictable.
Do not prescribe without baseline ECG + ECHO + controlled hypertension — carfilzomib has 5-7% rate of cardiac AE.
Do not skip baseline DAT/Coombs + red-cell phenotyping BEFORE first isatuximab — anti-CD38 interferes with crossmatch for months.
Do not start without HBV screening + entecavir prophylaxis in HBsAg+ or anti-HBc+.
Do not skip IV hydration (250-500 mL pre/post) for the first carfilzomib — TLS + AKI risk highest cycle 1.
Do not confirm plan without verified funding pathway — neither isatuximab nor carfilzomib are reimbursed by NSZU.
Do not escalate carfilzomib to full dose (56 mg/m²) without cycle-1 step-up (20 mg/m² days 1-2).

Aggressive plan (IND-MM-4L-TECLISTAMAB)

Do not start outside inpatient settings — step-up doses require ≥48h hospital observation for CRS surveillance.
Do not skip IVIG for IgG <400 — universal hypogammaglobulinemia + infectious burden is a leading cause of mortality.
Do not skip PJP + HSV/VZV prophylaxis — opportunistic infection risk is very high.
Do not continue with active uncontrolled infection — pause until resolution is mandatory.
Do not start without on-site tocilizumab (≥2 doses) for emergency CRS rescue.
Do not prescribe with baseline ECOG ≥3 — clinical trial excluded; on-treatment mortality very high in frail patients.
Do not forget about live vaccines — contraindicated during and ≥6 months after treatment.
Do not confirm plan without international referral pathway + funding — drug not available in Ukraine.

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Isatuximab + Carfilzomib + Dexamethasone (Isa-Kd), 28-day cycles

28-day cycles × Until progression or unacceptable toxicity

Aggressive plan

Induction · Teclistamab BCMA × CD3 bispecific (with step-up dosing) — continuous SC weekly

7-day cycles × Continuous until progression or unacceptable toxicity

MDT brief

Discussion questions (1, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (2 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (recommended) — for consideration (1)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ISS-1, RF-ISS-3, RF-MM-BCMA-EXPRESSION-POS, RF-MM-CD38-EXPRESSION-DARA-CANDIDATE, RF-MM-CORD-COMPRESSION, RF-MM-FRAILTY-AGE, RF-MM-HIGH-RISK-CYTOGENETICS, RF-MM-HYPERCALCEMIA, RF-MM-HYPERVISCOSITY, RF-MM-INFECTION-SCREENING, RF-MM-RENAL-DYSFUNCTION, RF-MM-T11-14-ACTIONABLE, RF-MM-TRANSFORMATION-PROGRESSION, RF-R-ISS-3-HIGH-RISK

Technical MDT skill metadata (1/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-EHA-EMN-MM-2025: EHA-EMN Evidence-Based Guidelines for diagnosis, treatment and follow-up of patients with multiple myeloma (2025)
SRC-ESMO-MM-2023: ESMO Clinical Practice Guideline on Multiple Myeloma (2023)
SRC-IKEMA-MOREAU-2021: Isatuximab, carfilzomib, and dexamethasone in relapsed multiple myeloma (IKEMA): a multicentre, open-label, randomised phase 3 trial (2021)
SRC-MAJESTEC-1-MOREAU-2022: Teclistamab in Relapsed or Refractory Multiple Myeloma (2022)
SRC-NCCN-MM-2025: NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma (v.X.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-07-15.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT04795882	A New Study Evaluating the Activity of Modular CAR T for mYeloma	PHASE1	RECRUITING	University College, London	—	Phase 1 only Small N (<50) Single country
NCT06182774	Fixed Duration vs Continuous Anti-CD38 Antibody Therapy Among Transplant Ineligible Older Adults With Newly-Diagnosed Multiple Myeloma	PHASE3	RECRUITING	Canadian Cancer Trials Group	—	Surrogate endpoint only Single country
NCT07214324	Integrative Multi-omics Analysis to Predict Monoclonal Gammopathies Clinical Evolution	N/A	RECRUITING	Azienda USL Reggio Emilia - IRCCS	—	Single country
NCT05572229	Study of Teclistamab in Combination in Elderly Patients With Multiple Myeloma	PHASE2	RECRUITING	University Hospital, Lille	—	Single country
NCT06580002	Repurposing Riluzole for Cancer-Related Cognitive Impairment: A Pilot Trial	PHASE2	RECRUITING	University of California, Irvine	—	Single country
NCT05259553	Biomarkers in Multiple Myeloma	NA	RECRUITING	Centre Hospitalier Universitaire de Saint Etienne	—	Single country
NCT07290309	Survivors Uniting for Remote Guided Exercise	NA	RECRUITING	Colorado State University	—	Single country
NCT07285044	The Cancer Connected Access and Remote Expertise Beyond Walls Program to Provide In-Home Cancer Treatment and Improve Treatment Satisfaction in Cancer Patients Living in the Florida Panhandle and Surrounding Areas	PHASE2	RECRUITING	Mayo Clinic	—	Small N (<50) Single country
NCT06207799	Pre-transplant Purging and Post-transplant MRD-guided Maintenance Therapy With Elranatamab in Patients With High-risk Multiple Myeloma	PHASE2	RECRUITING	M.D. Anderson Cancer Center	—	Small N (<50) Single country
NCT06100237	Teclistamab in Combination With Daratumumab for High-Risk Smoldering Myeloma: A Clinical and Correlative Phase 2 Immuno-Oncology Study (the REVIVE Study)	PHASE2	RECRUITING	Carl Ola Landgren, MD, PhD	—	Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Isatuximab + Carfilzomib + Dexamethasone (Isa-Kd), 28-day cycles (REG-ISA-KD-MM-3L) 1/3 component drug(s) not registered in Ukraine +1	✗ not registered	✗ out-of-pocket	₴-? — verify pathway	not recorded
Aggressive plan Teclistamab BCMA × CD3 bispecific (with step-up dosing) — continuous SC weekly (REG-TECLISTAMAB) 1/1 component drug(s) not registered in Ukraine +1	✗ not registered	✗ out-of-pocket	₴-? — verify pathway	not recorded
Trial · NCT04795882 A New Study Evaluating the Activity of Modular CAR T for mYeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06182774 Fixed Duration vs Continuous Anti-CD38 Antibody Therapy Among Transplant Ineligible Older Adults With Newly-Diagnosed Multiple Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07214324 Integrative Multi-omics Analysis to Predict Monoclonal Gammopathies Clinical Evolution No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05572229 Study of Teclistamab in Combination in Elderly Patients With Multiple Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06580002 Repurposing Riluzole for Cancer-Related Cognitive Impairment: A Pilot Trial No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05259553 Biomarkers in Multiple Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07290309 Survivors Uniting for Remote Guided Exercise No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07285044 The Cancer Connected Access and Remote Expertise Beyond Walls Program to Provide In-Home Cancer Treatment and Improve Treatment Satisfaction in Cancer Patients Living in the Florida Panhandle and Surrounding Areas No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06207799 Pre-transplant Purging and Post-transplant MRD-guided Maintenance Therapy With Elranatamab in Patients With High-risk Multiple Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06100237 Teclistamab in Combination With Daratumumab for High-Risk Smoldering Myeloma: A Clinical and Correlative Phase 2 Immuno-Oncology Study (the REVIVE Study) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-07-15.

plan_id: PLAN-VERIFIED-MM-L3-MM_3L_ISA_KD-V1 | version: 1 | generated: 2026-07-15T13:33:22.923165+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.