VRd is a treatment for multiple myeloma, a type of blood cancer. It is sometimes called RVd. VRd comprises the drugs Velcade, Revlimid, and dexamethasone.

Multiple myeloma (MM) is a cancer that forms in white blood cells called plasma cells. Over time, cancerous myeloma cells can clump in bones or bone marrow.

VRd uses three classes of drugs: a proteasome inhibitor (Velcade), an immunomodulatory agent (Revlimid), and a steroid (dexamethasone) to combat the growth of myeloma.

People who take VRd for MM also take preventive medications to reduce side effects. Most people tolerate VRd well.

This article will explain what VRd is and how each drug attacks myeloma. It will also describe potential side effects, how much VRd costs, and the outlook for people with MM.

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VRd, or RVd, is a type of targeted drug therapy that combines three classes of drugs to fight the growth of MM. A person takes the drugs orally, through an injection, or intravenously through a vein over a 21-day cycle.

Proteasome inhibitors are medications that prevent cancer cells from getting rid of old proteins. As enough old proteins accumulate, the cancer cells eventually die. Velcade (bortezomib) is a proteasome inhibitor.

Immunomodulatory drugs are workhorse drugs for the immune system. They can activate immune cells, kill myeloma cells, and prevent the growth of other types of bad cells. Revlimid (lenalidomide) is an immunomodulatory drug.

Steroids have many uses in myeloma treatment. They can relieve pain and pressure by reducing inflammation. They may be able to help with nausea and other side effects of chemotherapy.

In high enough amounts, steroids can kill myeloma cells. Dexamethasone is the steroid that doctors use for VRd treatment.

According to the International Myeloma Foundation, doctors usually recommend VRd for people who have not had previous treatment for myeloma and are eligible for a stem cell transplant.

The National Cancer Institute explains that younger, fit people are usually eligible for a transplant, whereas those aged over 75 are not. People aged 65–75 may be eligible, but it depends on their overall health.

In contrast, a 2019 review suggested that age should not be a barrier to having stem cell transplants.

Healthcare teams consider a person’s health factors and myeloma status to determine the right treatment. VRd is one of many triplet therapy combinations that doctors can prescribe.

Learn more about MM treatment options here.

What is MM?

MM is a cancer of plasma cells, a type of white blood cell in the immune system. Over time, myeloma cells accumulate in the bones and bone marrow.

An overgrowth of plasma cells in the bone marrow limits the space for normal blood-forming cells, leading to a low blood count. MM can also lead to:

  • bone and calcium problems
  • kidney problems
  • infections

Doctors do not know what causes MM. The average age of patients with MM is 70 years. Black people are more likely to have MM than white or Asian people. Asian people are more likely to have MM than white people.

A doctor will determine which type of myeloma a person has by taking a bone marrow biopsy. This also helps stage the disease, set a course of treatment, and determine an outlook.

Learn more about MM here.

According to the International Myeloma Foundation, a VRd cycle is 21 days long:

  • Velcade is an injection or intravenous (IV) infusion on days 1, 4, 8, and 11 of the cycle.
  • Revlimid comes in capsule form, which people take with water on days 1 through 14.
  • dexamethasone is a pill that people take with food or following a meal on days 1, 2, 4, 5, 8, 9, 11, and 12 of the cycle.

For a 21 day cycle, a person will receive treatment for 14 days, followed by 7 days off treatment.

Doctors can adjust this schedule to minimize toxicity for an individual, taking into account their health factors.

Velcade is a proteasome inhibitor, which doctors use alone or in conjunction with other drugs to treat MM.

What does it do?

All cells contain proteasomes that work to break down and dispose of unwanted protein within the cells. Small pieces of these proteins then create new proteins that the cell uses for new functions.

Velcade prevents a cell from breaking down proteins. Without normal function, myeloma cells stop dividing and creating chemicals that encourage other myeloma cells to divide. The myeloma cells eventually die.

Side effects of Velcade

About 20% of people experience side effects from Velcade. The most common side effects include:

  • nausea
  • diarrhea
  • low blood platelet count
  • low neutrophil count — neutrophils are a type of white blood cell
  • peripheral neuropathy
  • fatigue
  • neuralgia
  • anemia
  • leukopenia — low leukocytes in the blood
  • constipation
  • vomiting
  • lymphopenia — low lymphocytes in the blood
  • rash
  • fever
  • loss of appetite

More serious side effects can include cardiac or pulmonary toxicity, brain swelling, chemical imbalances, blood clots, or liver problems.

Learn more about Velcade here.

Revlimid was the first oral drug that researchers developed to treat MM. Doctors use it as part of a combination drug program or in conjunction with a steroid.

What does it do?

Revlimid is an immunomodulatory drug that enhances the immune system. It helps the immune system find and target myeloma cells for destruction.

Revlimid also impacts the blood vessels that tumors require to grow. It prevents the myeloma cells from attaching to the blood supply they need to develop.

People take Revlimid in capsule form once daily with water.

Side effects of Revlimid

There can be serious side effects with Revlimid. It can cause congenital disabilities or miscarriage, so it is not suitable for pregnant or breastfeeding females. In males, it can pass through semen.

Revlimid can cause decreased blood platelet and neutrophil levels. If a person has low blood counts, they may need a blood transfusion or extra medication.

Revlimid carries a risk of deep vein thrombosis, which are blood clots that commonly form in the deep veins of the legs. These can travel to the heart or lungs and be life threatening.

Other serious side effects include:

  • risk of new cancer developing
  • severe liver problems
  • tumor lysis syndrome
  • worsening of a tumor
  • thyroid problems
  • risk of early death in mantle cell lymphoma
  • severe skin or allergic reactions

Learn more about Revlimid here.

Dexamethasone is a corticosteroid similar to a natural hormone that the adrenal glands secrete. Doctors prescribe it to treat inflammation, pain, asthma, allergies, and cancer.

What does it do?

Dexamethasone treats the side effects of cancer treatments. It suppresses the immune system, which can become overactive during cancer and cancer treatments.

Side effects of dexamethasone

The side effects of dexamethasone include:

  • nausea
  • stomach upset
  • headache
  • vomiting
  • dizziness
  • insomnia
  • restlessness
  • depression or anxiety
  • acne
  • hair growth
  • bruising
  • irregular menstrual periods

If a person experiences the following side effects, they should seek medical help immediately:

  • rash
  • swollen face, lower legs, or ankles
  • vision problems
  • cold or infection that does not clear up
  • muscle weakness
  • black or tarry stool

Learn more about dexamethasone here.

Doctors may recommend 3–4 rounds of VRd treatment. They will periodically take a sample of bone marrow using a biopsy to monitor the progress of MM. Doctors can adjust a person’s treatment based on their findings.

Testing and treatment may vary according to whether a person is eligible for an autologous stem cell transplant.

According to one 2016 review, the cost of VRd can exceed $150,000 per year in the United States. There could be follow-on maintenance therapy which can exceed $100,000 per year on its own.

Medicare Part B covers drugs such as Velcade because doctors give them by injection or infusion in a medical setting. A person may still be responsible for paying a copayment and 20% of the Medicare-approved amount.

Medicare Part D covers drugs such as Revlimid and dexamethasone, although copayments may apply.

A person with private health insurance can contact their insurance company to ask what their policy covers.

The Leukemia and Lymphoma Society (LLS) offers financial assistance to people with MM. LLS may be able to help pay for copayments, deductibles, coinsurance, and costs related to certain treatments.

Data from a South West Oncology Group study showed that VRd treatment for MM significantly improves survival rates.

539 newly diagnosed patients were given either VRd or Rd without Velcade. After a 55-month follow-up, those on the VRd treatment had an average overall survival of 75 months, compared with 64 months in the Rd group.

The relative 5-year survival rate for MM is 55%. This means that people with MM are 55% as likely to be alive 5 years after diagnosis as people without MM.

VRd treatment comprises three medications: Velcade, Revlimid, and dexamethasone, which each have a different way of tackling multiple myeloma.

People follow a 21-day treatment regimen, which doctors can adjust based on an individual’s needs. A person usually has 3–4 treatment cycles.

Most people tolerate VRd treatment well, but it can cause undesirable side effects.