The field of multiple myeloma has transformed from having few treatments to an abundance of effective drugs. The primary clinical challenge is no longer finding a therapy that works, but rather determining the optimal sequence and combination of available options, highlighting a unique form of market maturity.

Combining Bellemaf with VRd induction for newly diagnosed, transplant-ineligible myeloma yields 100% response rates. This potent efficacy is driving its adoption in earlier treatment lines, with the clinical focus shifting to proactively managing its known ocular toxicities through dose adjustments and holds.

A key trend in 2025's drug approvals is that "best-in-class" therapies are distinguished not just by efficacy, but by innovations in formulation and delivery that improve the patient experience. Examples include subcutaneous versions of IV drugs and new delivery methods that expand patient access.

Subcutaneous on-body device delivery of anti-CD38 antibodies like isatuximab nearly eliminates the high risk of infusion-related reactions common with intravenous administration, especially during the first dose. This significantly enhances patient safety and comfort in the clinic.

Unlike older IMiDs where T-cell effects are secondary, CELMoDs have a powerful, independent pro-T-cell mechanism. This dual action is so significant that in the future, CELMoDs will be prescribed not just for their direct anti-myeloma effects, but specifically to enhance the efficacy of T-cell therapies like CAR-T and bispecific antibodies.

The Determination II trial chose isatuximab over daratumumab for its induction regimen based on two factors. First, it may have an edge in high-risk myeloma (1q amplified). Second, its less frequent dosing schedule (weekly for one month) reduces the myelosuppression seen when combining iberdomide with daratumumab.

An expert who initially viewed CELMoDs as incremental improvements now considers them fundamentally different. The new litmus test for future myeloma trials will be tracking prior patient exposure to CELMoDs like iberdomide, just as they track prior IMiD exposure today, cementing their status as a distinct therapeutic category.

Using a BCMA bispecific antibody first can exhaust a patient's T-cells or cause tumors to lose the BCMA target, rendering a subsequent BCMA-targeted CAR-T therapy ineffective. The optimal sequence is CAR-T first, which preserves T-cell function and BCMA expression, leaving bispecifics as a viable later-line option.

Historically, intratumoral therapy was limited by the physical difficulty of reaching tumors. The rise of a new discipline, Interventional Oncology, has largely solved this access problem. The critical bottleneck is now the lack of drugs specifically designed and optimized for local delivery and sustained retention within the tumor.