Bortezomib for induction therapy in multiple myeloma before high-dose chemotherapy and autologous stem cell transplantation

Bortezomib (Velcade, Janssen‑Cilag) is an anticancer drug that works by reversible proteasome inhibition. By inhibiting proteasomes (multi-enzyme complexes present in all cells), bortezomib interferes with the cell cycle leading to cell death. It is administered by intravenous infusion or subcutaneous injection. Bortezomib has a UK marketing authorisation for use 'in combination with dexamethasone, or with dexamethasone and thalidomide for the induction treatment of adult patients with previously untreated multiple myeloma, who are eligible for high-dose chemotherapy with haematopoietic stem cell transplantation'.

The summary of product characteristics lists the following as the most commonly reported adverse reactions for bortezomib: nausea, diarrhoea, constipation, vomiting, fatigue, pyrexia, thrombocytopenia, anaemia, neutropenia, peripheral neuropathy (including sensory), headache, paraesthesia, decreased appetite, dyspnoea, rash, herpes zoster and myalgia. For full details of adverse reactions and contraindications, see the summary of product characteristics.

The cost of bortezomib is £762 per 3.5‑mg vial (excluding VAT; BNF, edition 66). According to the marketing authorisation bortezomib should be given in combination with dexamethasone (4 cycles of 21 days each) or with dexamethasone and thalidomide (4 cycles of 28 days each; 2 additional cycles of 28 days each for patients with at least partial response after the fourth cycle). Four intravenous infusions or subcutaneous injections of bortezomib are administered per cycle, on days 1, 4, 8 and 11 of each cycle. The average cost of a course of treatment with bortezomib given with dexamethasone is estimated to be £12,261 and the average cost of a course of treatment with bortezomib given with dexamethasone and thalidomide is estimated to be £24,840. Costs may vary in different settings because of negotiated procurement discounts.