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Answer 5
  1. Bortezomib. The patient’s MM is not responding to TD therapy. Increasing the dose of thalidomide is unlikely to induce a response and will probably aggravate the early therapy-related peripheral neuropathy this patient is already experiencing. Although there is some risk that bortezomib may cause worsening neuropathy as well, it is the best choice from the remaining 3 options for a patient with significant renal insufficiency. It has been shown that bortezomib can be given at full dose in the presence of severe renal failure6 and can induce responses in approximately 35% of patients with previously treated MM. Melphalan and lenalidomide are both problematic in the setting of advanced renal failure, although guidelines for dosage adjustment are available.

    6. Jagannath S, Barlogie B, Berenson JR, et al. Bortezomib in recurrent and/or refractory multiple myeloma. Initial clinical experience in patients with impaired renal function. Cancer 2005;103:1195-200.

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