Harsh Parmar MD
1.4K posts
Harsh Parmar MD
@Phhersh
Myeloma and Amyloid Oncologist, Asst Professor of Medicine@hackensackUMC. Local guide NYC restaurants. Ravenclaw. Tweets are my own
Hackensack, NJ 参加日 Ağustos 2009
305 フォロー中373 フォロワー
$100 to anyone who predict ARSENAL VS MANCHESTER CITY score correctly!
Must following us to be contacted💵
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@rajshekharucms @bdermanmd @CoMMitTrials Voted for cart but a Lot of options beyond cart. Pt is still PI sensitive, (carfilzomib combos)linker-mm2 data looks quite strong (PI+ TCE when apptoved). I believe TCE with imids or celmods (even if imid resistant) would be the way in the near future
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@bdermanmd There are no RCTs with ASCT in relapsed myeloma TMK that have outcomes as impressive as CART-4, MajesTEC-3 (and soon, Tec-9 hopefully). Even in frontline setting, I think BsAbs will decimate ASCT (eg in FASTER trial by @CoMMitTrials).
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For a contemporary patient with myeloma that receives Dara-VRd induction, forgoes ASCT, and proceeds with maintenance, what would you recommend at relapse (assume Dara-R resistance)?
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Agreed – domestic cups (FA looks winnable, Carabao final vs City is 50/50) fit the pattern. EPL slip risk is real with City's form and Arsenal's historical late fade. UCL vs Leverkusen is tight but possible. Chelsea win today keeps the title pressure on; loss, and it's basically over. Still leaning 2 max for me. Your final call?
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The image was a straight edit to "delete" the trophies per the original ask—pure banter on the quadruple dream.
Breakdown: Arsenal lead PL (61 pts/28 games, +35 GD) but City 2 pts back & in form; Carabao final vs City (Mar 22) = low odds; FA Cup 5th rd vs Mansfield = very winnable path; UCL R16 vs Leverkusen = even but knockout risk. History of late slips & City rivalry tips it to 1 (FA) max. Solid squad, but 4 is dream territory. Your 2/4 take?
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@Arsenal_rep1 I hope zero points and lets concede this season. What a waste- sign better forwards, so many missed chances
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Arsenal fans, How many points are we getting from three games??
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@tejjuhstring2 @Arsenal Wolves scored all 3 goals..and still lost
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@RahulBanerjeeMD I dont claim credit for any of this, I got this idea by reading one of the tweets from @Myeloma_Doc and picked up the functional igg idea from @Taxkourel when I was a trainee
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🤯 another strategy to get IVIG approved for bsAbs in #MMsm as it should be…
This is brilliant - thanks, Harsh! we shouldn’t have to play games to get approval for urgent safety measures, to be fair, and hopefully this will get easier with time!
Harsh Parmar MD@Phhersh
@RahulBanerjeeMD @JosephMooreMD @NoopurRajeMD @KRejeski @GKaurMD @gjmccaughan @DrNikitaMehra @MeeraMohanMD Check igg subclass if igg is normal (if any one is low can start ivig, ive gotten away with this) or if there is an m-spike, use ‘functional’ igg method if the mm isotype is igg
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@Taxkourel Mechanistically, not very excited about dara + tec mainly because dara depletes APCs profoundly, besides the increased infectious risk signal. Curious to know why you dont prefer this combination either
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2) Are we "shooting ourselves in the foot" by using a BCMA TCE before a CART? Would maybe fixed duration Tec make more sense? 3) I think if Dara ref I am happy to have Tec available in earlier lines and get "creative" with it (would not give with Dara personally) .:-)
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Vincent this would be a great Monday meeting discussion. Here are my points of confusion 1) Ciltacel 2nd line in Dara naive makes me pause. here is the OS curve for 2nd line patients with Ciltacel (source fda.gov/media/176986/d…). Tec-Dara would obviously be way safer but... 1/
Vincent Rajkumar@VincentRK
OK here it is. Finally. My #ASH25 algorithm for Relapsed Myeloma: First Relapse. Discussed with @YiLinMDPhD @myelomaMD Give comments. I’m willing to adjust it based on your insights.
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@hhashmi87 @GKaurMD @rajshekharucms In MM therapy generally, we need to more critically examine whether MRD+ pts benefit from more tx. It’s clear they have inf outcomes, but it’s uncertain whether more of the same tx remedies this. Answer likely differs by mechanism and clinical setting.
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@rajshekharucms IMO time limited Rx should be guided by time to MRD negativity data in the trial. ~90% achieved MRD neg by 10-6 (evaluable dataset), vast majority sustained at 6m. I would suggest stopping Rx at 12m if MRD neg. No drop in the PFS curve beyond 12m!! #MMSM #ASH25
Raj Chakraborty@rajshekharucms
Also, sounding like a broken record, but we must strive for a finite duration, especially with Tec-Dara. I can’t imagine giving this for 8-10+ years. Hope @JNJInnovation will provide data on long term durability of response in patients who discontinued for reasons other than PD/Death. #ASH25
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@RahulBanerjeeMD @JosephMooreMD @NoopurRajeMD @KRejeski @GKaurMD @gjmccaughan @DrNikitaMehra @MeeraMohanMD Check igg subclass if igg is normal (if any one is low can start ivig, ive gotten away with this) or if there is an m-spike, use ‘functional’ igg method if the mm isotype is igg
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@JosephMooreMD @NoopurRajeMD @KRejeski @GKaurMD @gjmccaughan @DrNikitaMehra @MeeraMohanMD Oh my goodness.... yikes!! Such a silly impediment and waste of the patient's time.
I'm hopeful that getting these into guidelines - plus even more analyses at #ASH25 showing significant benefits - will turn the tide!
GIF
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#ASH25 saying it louder for everyone in the back!
If you are starting a bsAb in #MMsm (especially BCMA), don’t wait for patient to die or IgG to drop. Start IgRT now!
Newest case in point: excellent IFM 2021-01 trial. Only 14% Gr3+ infxns despite older pts & CD38 pair!
Ben Derman@bdermanmd
TecLille: Tec+Dara in transplant ineligible NDMM n=37; median age 73 (!) Very high MRD negativity rates even at 6 months! Very interesting correlatives, including clonotypic peptide sequencing and sBCMA. No progressions. No deaths. 14% grade 3+ infections (nearly everyone got IVIg starting within first cycle). If this regimen can be so well tolerated upfront even in older adults, that bodes very well for the future of bispecific antibodies in frontline therapy.
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A hot question about to get hotter. The importance of "sequencing " is contingent on the failure of the earliest therapy. 😉
Taxiarchis Kourelis@Taxkourel
@End_myeloma Honest question i am struggling with: How do we sequence with CART first line that is also moving up?
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@FCBCollins @TrollFootball We’ve come a long way from Wenger’s days. Corners and set pieces were useless and defense was shaky back then. Now with gab, saliba, timber and calafiori, defense looks more solid than ever. ‘1-0 to the arsenal’ days are back again (i dont mind)
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@Phhersh @TrollFootball Corner FC
Set piece FC
That’s a good tactic though
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@FCBCollins @TrollFootball I love corner FC. Every arsenal corner is like a penalty
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@TMSchmidtMD @bdermanmd Agree, I use DOAC as well with car and imid. (I use car for Ndmm)
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@bdermanmd Thanks for sharing this! I have been using DOACs for patients with K/imid combos and high risk for thrombosis (prior VTE, recent surgery, immobility), but not most who get DaraVRd. Have been thinking about switching, and this data is probably enough to make DOAC the standard!
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One recommendation I make over and over is to use a prophylactic DOAC instead of aspirin in newly diagnosed myeloma.
Just choose a DOAC [they are getting much more affordable!]!
*⃣Risk scores lack validation for choosing VTE ppx.
😀The BENEFIT trial shows 6-month incidence of VTE was 0.8% in patients receiving ppx DOAC vs 5.6% with ppx heparin, and 9.8% in patients receiving aspirin.
pubmed.ncbi.nlm.nih.gov/40523501/
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@simonmaechling May be go one step further and say humans are no different than anything (live or dead) at all at a subatomic level. ‘The universe and I are one.’
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Humans share 100% of their DNA with all known living species: A, C, T, and G.
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