COVID-19 and What Multiple Myeloma Patients Need to Know

[Music] welcome to today's episode of myeloma crowd radio show that connects patients with myeloma researchers I'm your host Jenny ahlstrom and we'd like to thank our episode sponsor bristol-myers Squibb for their support of myeloma crowd radio and for this particular program I think all eyes and ears are on a corona virus and many my little patients are being impacted by it for all aspects of their care dr. joshua richter is at Mount Sinai in New York City one of the epicenters of us outbreak today and he's very aware of how it's impacting his myeloma patients and those around the country so dr. Witt Richard welcome to the program thank you so much for having me so before we get started let me just give a short introduction for you we have a lot to talk about dr. Joshua Richter is assistant professor of medicine at the Tisch Cancer Institute at Mount Sinai at the Icahn School of Medicine in the multiple myeloma division dr. Richter previously practiced with the John Theurer Cancer Center and at Hackensack University and the Wreckers over the course of his career dr. Richter has led significant research on the development of new or novel multiple myeloma treatments including Parcells in them so an EXOR panobinostat Derek to mohammad amide isit exome and an assassin and his research also includes immunotherapies simple transplant and optimal treatment strategies in multiple myeloma so I think we'll just jump right in to the show today because it's such an important topic and relevant takut topic but what are you seeing or how are my little patients being impacted by this corona virus and what considerations are you taking it in account before just about everything I think so obviously this is the most important question that we're all dealing with and you know one of the things that I have to say is you know despite the the concern that everyone has the medical community and the myeloma community is banding together in ways that have never been done before to make sure that everyone gets the optimal care during these crazy times so you know there's some broad things that we're doing and then much of what we're doing is patient by patient so from a broad standpoint we're trying to limit quote-unquote non-essential things and you know that's complicated for a myeloma patient what's essential and what's not transplants for one are not always essential so for number of patients with newly diagnosed myeloma we give induction therapy and then the plan is to go on to transplant many people achieve a good remission with the induction and if we're able to hold off on transplant right now we are and the big reason is that transplant requires not only a several week stay in the hospital which may be more risky at this time but it also suppresses the immune system and we want to make sure that everyone's immune system is as intact as it possibly can be during this time we also very much encourage social distancing is as much as can be done and thankfully in many places the ability to order food and/or drugs and other supplies is available in terms of day to day therapy we're trying to switch over as much as possible to oral therapies so there are a number of oral therapies that patients are very familiar with drugs like Revlimid and pomalidomide there are some oral therapies that people may be less familiar with drugs like excess mid cell and xrn panobinostat and what we're doing for many people is trying to utilize regimens that use oral drugs this way people don't have to come in on a weekly or twice weekly basis to their offices and hospitals to get infusions so accessible is produce um inhibitor much like delicate or carfilzomib and for many intents and purposes it's it's very similar to an oral version of Velcade so many people that are receiving Velcade we're switching over to X as an opponent morrow kind of been is that is another drug that's core it's not as commonly used but an extremely efficacious drug and can actually resynthesize to previous drugs meaning if someone's on Revlimid and revlimid stops working you can add cannabis that Andry sensitize them so we're in some cases we might have added Velcade previously or dara tune the Maverick refills on it now we can add drugs like panobinostat to control the disease without needing multiple visits and cell NXR is another amazing oral drug that was recently approved but we know that we can combine with other oral drugs including drugs like pomalidomide so we're really trying to switch things over to oral as much as possible and limit the number of blood tests that is needed because you still need to go out to their lab drawer Center or your hospital to get blood draws so really spacing things out and having regular communications with patients including things like telemedicine so a lot of places are embracing telemedicine to have video chats through our phones and our devices to talk to patients to go over their symptoms review plans of care help manage as much as possible so that people don't have to unnecessarily expose themselves to anything outside okay that's a lot per mile of patients to take in so let me let's just break it down if we don't if you don't sure to some of course a big thing so you talked you mentioned testing in blood drives so if I'm going in let's say monthly and I guess it depends on how your mind Lola is behaving like if you're in remission status and you're getting tested every three months so what you're saying is you could just push that out and maybe wait an extra month to get testing if your myeloma looks like it's behaving appropriately absolutely I mean at case-by-case and patients should definitely talk to their care teams but your sentiment is 100% correct for patients who you know we do a lot of things out of routine for optimal strategy but if we're checking things every one month for many patients we can switch it to two or three or even beyond so I completely agree with you and then for patients who have maybe increasing myeloma what are you recommending for them in terms of testing or blood drives so you know that's a more complicated issue so the you know there's two types of progressions that we generally talk about in myeloma biochemical and more aggressive biochemical is where we're measuring the EM spike or the free light chains and they're just starting to come up but people feel otherwise well I think in those scenarios we're trying to add oral drugs to compensate so if you're on Revlimid and progressing we can Adnan Lara can add panobinostat we can add cell and X or to help control that for people who are having more aggressive progression of disease their kidneys are starting to feel the pressure or the more anemic where their calcium is going up there's what we have to have a more complicated decision so we still are having are the availability of the clinic and all of its resources and just continuing what we would do otherwise but just take more precautions okay well I want to jump into a question so I don't forget it going forward because you talked about different options and it's probably better if we talk about it later but I don't want to forget it so you mentioned fellow next door and I know a lot of because it was just barely approved there are a lot of doctors that don't understand how to use it and how to mitigate the side effects that you have with Scylla next door and if they're managed properly it can be just fine so do you want to review a little bit about that so that actually as they go and talk to their doctors like I need want to try this and the doctor I've had community doctors will be push back and go I don't know how to use this drug yet no I think that's a you know that's a really critical question so cell next door was originally approved July 3rd of last year I was approved based on the storm study and the storm study looked at just giving cell and XO and dexamethasone as pills with no other myeloma regimens and in order to achieve a high enough response rate to get the drug approved the drug needed to be given twice a week at 80 milligrams however it's a little more toxic to give it that way and it's far better to give it once a week but if you give it once a week you have to mix it with another myeloma drug so that you get enough synergy and it works even better and this actually comes true from the Boston study which was just read out as positive a week or so ago where we combined selling X or Velcade impatience do amazingly well and instead of getting eighty milligrams twice a week we give 100 milligrams once a week so optimally the drug is given once a week and the dosing is different depending upon which drug you give it you give it with Garrett Summa mcarthism ever Velcade it's 100 once a week if you give it with pomalidomide it's probably 60 once a week with Revlimid it's probably 60 as well sometimes pomalidomide you can put it up to 80 but 60s probably the better does the other thing to mitigate it is it's far better to be proactive than reactive in terms of side effects so we find that if we're very aggressive about preventing side effects they happen in much fewer patients as opposed to dealing with nausea or other problems after they have it so we give a combination of medicines to prevent it things that are a little bit out of the box so ver OB is a drug we use quite often which is similar to Amend which some people may take we give drugs like zofran and steroids and another one is as iPrEx a' or olanzapine which is originally marketed as an anti-psychotic drug but actually has a lot of great efficacy to prevent nausea and Gi side effects and again these are all pills so what we are doing is giving people many prescriptions unfortunately there becomes a higher Tilburg in this case but it's a way to prevent symptoms and control the disease and so if that study the bosses study I know is using someone XOR with Velcade and dexamethasone would you consider using molaro in place of it with so linux or in dexamethasone it's a really great question there's not sufficient data that I've seen yet with NIMH laro but in the stomp study which combines sound XR with a whole bunch of other drugs we have data with cell and exon Revlimid and cell next door and pomalidomide so the best data so far is an all oral combo with cellie would be selling X or pomalidomide index and really great data coming out of this Dom study for that okay so that might be something doctors might feel more comfortable applying for a temporary situation hello yeah that that would that's a really unique approach and same thing with the same question for panobinostat like what do you combine that with if you're thinking about pushing kind of in a set but it's a phenomenal question so you know the Penn administer that was approved and about 2014-2015 and it was approved based on the panorama study combining panobinostat with Velcade um they've been another number of smaller studies now giving it with drugs like car fills MIT and more recently looking at combining it with image Revlimid and pomalidomide um and we've actually at our Center been using these combos for quite some time with a lot of success on there are a few unique things you have to look out for to make to make these optimal um the main thing about panobinostat is in the original study it was given two weeks in a row in one week off and we found that it caused a lot of GI issues mostly diarrhea but if you give it every other week it's actually tolerated way better so I saw a patient yesterday as having progressive disease and I put him on Revlimid panobinostat index the panobinostat dose every other week and he's going to go locally for blood work and we'll review it by a video visit every two weeks to monitor things um so because the drug actually resented eise's and we have data showing this that if you become refractory to a drug like Revlimid or pomalidomide kind of Bennis that can actually resynthesize the tumor and make those drugs useful again so even if you're refractory to some of these drugs we can actually still recatch you with an all oral regimen Wow so this is just amazing because the creativity that you I mean you're already on myeloma specialist and we highlight all the time how patients need to go talk to myeloma specialist to get their care crafted but in moments of you know distress and crisis that we're having right now it's even more important so when you think about you mentioned telemedicine can patients reach out to a new myeloma doctor is that let's say they get their care locally and they have somebody helping them kind of craft their treatment strategy that's local that may not know that much about myeloma it are there telemedicine options to get a second opinion with somebody like you or or have another person because that okay 100% I literally saw two patients yesterday that I've never met before I saw them via telemedicine visit and when I got off the phone with them I called their local doctor to discuss all the details and email them line notes the reality is that much of what we do is reviewing charts and having conversations and a lot of this can be done by a telemedicine so we have new patient visits that are already set up that we're converting them all to new patient visits unless there's some outstanding reason and there are a select group of people who still need to come in if they're having severe complications and we need to give them aggressive medicine immediately but if it's for a second opinion absolutely reach out to any of the major myeloma centers many of us are already set up for telemedicine have been doing it for a long time happy to do that okay and we have on myeloma crowd directory as well on our web sites if you go to my mama crowd org under the find tab you'll see a list of minimum of doctors and if anybody has trouble getting in touch with some of the doctors please just email me at info at Proctor at work and I'm like sure that they get the message so let's talk about that because you mentioned for people who still do you have to come in so people are coming in for infusions like there are to remove and and and carpels nib or even belkaid or things like that do you want to talk about potential strategies patients could think about in terms of their time being and their locations and the frequency and and all that in a little more detail no no absolutely so I think it drug by drug so Derrick suma map luckily has a very long half-life so there's a general step up the way Derek in the lab works is not exactly like a normal chemo where you give more and it does more as an antibody drug think about it that every tumor cell has a lock and the diet room that is the key and as you build up the levels in your blood every lock has a key in it and by dumping more keys you don't necessarily make things better and these keys hang out for a very long time so what we're doing for some people is accelerating things and really getting them to a less frequent dosage sooner instead of once a week pushing it twice a week or even once a month and again many patients who are seen at a variety of different centers or go for second opinions our general recommendation is that if there's a drug that's commercially available to get treated locally and we are more than happy to continue to work with all of the local doctors to ensure everything is going smoothly for elotuzumab another IV drug many people are still giving it the classic way from the original study which was 10 milligrams per kilogram every week for eight weeks followed by the same dosage every two weeks with more recent studies we know that we can double the dosage and have the visit times you can push it up to 20 milligrams per kilogram and give it once a month and this allows people to continue on effective drugs but get them less frequently Velcade a lot of our Velcade we're switching over Dan and Laura because is very similar efficacy and it's a very useful drug car fills amid what we're trying to do for patients who require that drug is many of the original protocols gave it twice weekly we're reducing that to once a week yeah I have seen a lot of studies talking about once-weekly karpova of dosing and lower side effect profile and things like that too and just as efficacious so it seems like that would be a really great option absolutely and we actually know that as you crank up the dose you can even sometimes even get better responses so the recent arrow study when we compared the classic twice a week dosing at 27 versus once a week dosing at 70 the once a week dosing was actually superior and again in times like this that combined with fewer visits to a doctor's office is very advantageous mm-hmm we're going to learn a lot using all these different and new combinations so I think so so as well so I the Texan that was just approved and it's a similar in the same class with Derek in lab what's your opinion on the use of that use of toxin I have is a phenomenal drug in the lab it appears to be slightly better in when we actually give it to patients it's hard to say it's a very very similar one of the big advantages to ISA toxmap especially during this time has to do with the first dose so many people who may be listening they know that first go cetera to the mat can take to ten hours the second dose can be six to eight hours now we do have a subcutaneous version of their Attila map that's going to come along any day now but we're not there yet the benefit of these approximate is that those first couple doses instead of eight to ten hours the first ones like four hours and instead of the second one being six to eight it's more like two to three so one of the great advantages right now is it's tolerated very very well very efficacious drug and reduces the amount of time you're in a clinic so interesting and for these I mean a lot of times what you're doing with your patients here you're doing telemedicine with you're sending the doctor's orders and I think a lot of patients sometimes don't know that you can get a consult with a myeloma expert and you don't have to get your treatment there necessarily it's like not you don't have to drive into New York City and get treatment there you can get treatment at home and you can do what you did with the other patient which is just craft the strategy tell the local doctor what to give and how to give it and I think the patient's just need to be reminded of that 100% the one thing I would add that we're very much encouraging at Mount Sinai is just as it's always a good idea when you come to a physician's visit to bring somebody else with you too because you never pick up everything for telemedicine visits it's no different so we're very much encouraging that when we do the telemedicine visits if if there's someone else in the house to listen and great or to kind of conference in somebody else because we know that in these stressful times no one's gonna remember everything so you know the same thing for regular appointments having somebody else listening to the information is very much encouraged yeah I totally agree there's a lot that's covered and it goes quickly and you don't necessarily catch everything because you're thinking about other things like you know not leaving your house is just yeah crazy okay so when you talked about let's go back to stem-cell transplant you touched on at the beginning about potentially delaying transplant for those people and maybe staying having a few more cycles of your induction therapy and kind of pushing it out if for those who have a plan transplant that's kind of your strategy it sounds like for those who are just finished with transplant or our high-risk and really need transplant as one of their options what do you suggest so again this is really at the end of this is a patient by patient discussion which is what we're doing with everyone um in general even in the high-risk settings um you know it is still if you have an excellent response to induction there's still some people who question the role of transplant I think that the the two questions that we think are as of as one do we already have stem cells if you already have stem cells the timing is a little more malleable we don't have stem cells you have to make a few other decisions so I saw a lovely person the other day telemedicine visit receiving car fills in the blender to my dexamethasone induction amazingly well we want to hold off on collection right now so we know that drugs like Revlimid if you have too much of it it makes it harder to collect stem cells so for this gentleman and many others we're dropping the Revlimid containing them on their Velcade or carfilzomib on and borrow or car salesman and just letting them remain in remission with regular blood work following them closely until we kind of figure out the optimal risk benefit to collect cells for transplant for people already have so same thing if you already have stem cells and you're on a regimen that's working we encourage people staying on that regimen and we know that this is not an unreasonable strategy so there was a reason there's an ongoing trial called the for case study really great study it's three arms in one arm people get the newly diagnosed myeloma karposev cytoxan dex plush transplant carfilzomib Revlimid dex plush transplant or car fills in the Revlimid x no transplant they just stay on it for 12 cycles and in both cases the krd arms did better you know there's definitely a hint that the people of high-risk do better with transplant but continuing on your induction for more than the four to six cycles there's nothing wrong with that and for many people they may even optimize things for when they do go to transplant so we're really trying to avoid it unless it's the only choice that really makes sense so we talked about the immunotherapies are there any other specific drugs that you want to discuss that in terms of administration or differences in administration during this time no I mean III think the the only other drug that we're talking about very heavily is IVIG so for many people have myeloma they get multiple infections and one of the ways that we kind of boost your immune system or increase your immune your normal immune globulin level is to give a drug called IVIG or intravenous immunoglobulin now there are some risks and benefits the main benefit is of course that it helps protect against infections one of the potential risks is that if you're getting it once a month that's an extra visit to the doctor so again we're discussing this on a case-by-case basis and one of the ways we do this is measure your IgG and we know your history if you have an IgG level and that's your immunoglobulin level that's 200 which is extremely low and when you're off the IVIG you end up in the hospital with pneumonia you need to continue IVIG if your IVIG your IgG level is normal and you haven't had an infection in two years we're going to hold that especially now that we're getting into some of the warmer months or some of the non kovat infections like RSV and influenza are going to go down right that makes a lot of sense okay can we talk about just weakened immune systems in general um do any of the medications I know like if patients are on a lot of myeloma therapy for a really long period of time sometimes they can have a weakened immune system so are there any drugs that patients should kind of steer away from or or you know what's your opinion on that so I mean I think that's a really really great question and myeloma is of course the hardest quite place to answer because myeloma itself the bad cells weaken the immune system and when we give some of our drugs they may weaken them further um the the quick and easy answer is it's a case-by-case basis um but there are some strategies that were taken in some people who are on many different drugs let's say they're on Dara - mmm Revlimid and dexamethasone have been on that for a very prolonged time we may stop the Dara 2 min map literally to avoid them having to come into the hospital but the other benefit is that it does relax some of the pressure off the rest of the immune system may give them a little bit of immune recovery so it's a win-win for some patients who it's clinically appropriate to back off on their therapy so yeah I think the best thing we can do is you know as a case-by-case really you know personalized medicine is really this who needs to still be on the aggressive medicine whoever we just kind of kept on aggressive medicine because that what seems to be the right thing but now may be suboptimal well you're weighing risk and benefit right so and you have to do that based on that individual person it yeah let's talk a little bit about drugs like immunotherapies that are currently in clinical trials because this situation is having a huge impact on clinical trial participation and joining new clinical trials or even releasing new clinical trials do you want to just share your perspective absolutely I just got off of a phone call on about 20 minutes ago or just before this arm about clinical trials and it's complicated right now so for those who don't know clinical trials are things that we do when a drug is not yet approved and we need to run them through testing to make sure that they're safe and what the right dose is for patients so you know this affects people at a lot of levels one is people who are already on clinical trials people are already on clinical trials if the drug is working we want to continue it on every trial has a list of requirements that the FDA and the trial puts you through and the FDA is actually released some guidelines to let us know that you know do what's appropriate meaning if you're on a clinical trial and you're responding well and it tells you that you know you need to come every week for blood work but your blood work has been great for months we can back off we don't need to do it every week and the FDA is going to let us know that that okay in the long run so we're trying to make adjustments but if you're responding well to a clinical trial we're trying to keep you honor for people who are going to go on clinical trials the landscape of trials in myeloma has changed across the last decade so a decade ago most of the trials were for people with no other options nowadays many of the trials that we put patients on there are other options and if there is a standard of care option that is at least as good we're going that direction so we're really trying to limit people going on to clinical trials right now kind of across the board again the handful of patients who really need it because there's absolutely nothing else available we're evaluating on a case by case basis but the reality is for many people and obviously not all but for many people go on trials there are other options I think the big thing this is impacting is a lot of people are very interested in going on to karti studies by functional antibodies and again the same principle applies where if we have another option to put you on in the meantime we will because the type of immune suppression you get with a Carty may put you at unnecessary risk for infections during this time how long does that typically last with Carty the immune suppression yeah it's it's so there's two types of immune suppression that we get with car teas one is cellular and the others humoral cellular is where your white blood count is low and for some people that can last months um and the others humoral those immunoglobulins or antibodies that you make that can be low for even longer so for some people they have a good amount of immune suppression that can last for three to six months and again it's not that that is an insurmountable feat but right now if we were going to put someone on a car T at their first relapse instead of giving them something like Dara to man Revlimid or Revlimid and then Lara or something like that we may opt for a standard of care at the moment hmm interesting so is the situation the same for the bikes and the antibody drug conjugates in your opinion absolutely so it's the same thing because the main risk of car T's is the cytokine release syndrome where when we put the car T into the patient it activates the immune system and releases all these chemicals we call cytokines and you can have high fevers low blood pressure confusion it can be very serious that bites have the same risk so many of the trials right now with by functionals or bites require multiple admissions to the hospital to monitor for CRS we don't want people being admitted three times in three weeks to the hospital right now so those trials are shut down the antibody drug conjugates are very interesting because we're on the cusp of at some point in the next six months having Balanta mad NAFA Doulton this big B CMA antibody drug conjugate approved so I think at the moment we're anxiously awaiting that drug to come out is another tool in our tool belt um but it's it's going to hold up those trials as well for the moment mostly from the requirements that trials need to keep you on study yeah okay well it's really shifting a lot of things for a lot of different people in the development that's happening in myeloma is so stunning that I just don't want that to slow down because we do need these new therapies absolutely no it's something that's absolutely critical and one of the things that we're kind of hoping is the next few drugs that are going to be approved the lanthum AB and BB 2121 a lot of this is just waiting for the final information to kind of reach significance and be filed with the FDA and although the FDA is going to be spending much time working on kovat related therapies at the moment we're hoping that this doesn't slow up those approvals and that we can get them out to our patients who need it as soon as possible right because they're pretty close to being a crook it sounds like so what about issues that patients should consider so who is specifically at the highest risk for developing this virus in terms of money patience absolutely so you know it's something that we have to kind of extrapolate from the data we have um the data that we have and doctors are joining from all over the world to share pieces they have is literally changing moment to moment hour to hour um and some of the biggest data we have comes from little de Provence in Wuhan China where they kind of publish this paper on March 9th in Lancet which is this big Journal talking about who really gets sick and it seems that the people who really get the sickest or people over the age of 80 or people who are over the age of 60 who have significant comorbidities the biggest one being lung issues so for people who are older or over the age of 80 those are the people who are at higher risk who really should practice social distancing as much as possible and I always tell them for essentially all these people they spend their lives helping people helping their families helping their friends this is a time to let us help them have your neighbor have your kids send food to you as you can social distance or for people who over the age of 60 you have significant comorbidities especially alone so people have underlying COPD or asthma those are the people we really worry about so if you have underlying lung disease the same thing applies you have raised friends and family throughout the years it's time to lean on them to help you and I think those are the big watchwords we're trying to convince everyone of them ok great and what about other normal comorbidities that come with myeloma like kidney issues or are you seeing any greater incidence or concern for people like that so the one thing that is very much in question is being debated quite a bit is you know when the kovat virus started one of the big questions that everyone was asking is how is it that older people seem to be getting sick but younger people don't and again it's not that younger people don't get sick they can still get it they can still pass it along but the very severe illness seems to be limited in younger people and one of the theories and again this is early on and the data may change tomorrow is that it relates to an enzyme called ace angiotensin converting enzyme and this is a chemical that's in our body that relates to our kidneys and blood pressure in fact many people out there may be on ACE inhibitors if you are on a drug that ends in the word Pro enalopril quinna Pro are those erase inhibitors and it seems that some of the people get sicker on this mechanism may be over activated um but the question we all ask as well as here we all stop our ACE inhibitors and the American College of Cardiology said no there's no events to stop them so the recommendation is not to stop ACE inhibitors in terms of other drugs to take or avoid there's a bit of a conflicting data about NSAIDs drugs like Advil or ibuprofen or leave in a person originally the w-h-o released the statement that patients should avoid Advil or NSAIDs and take tylenol instead they just released some statement today saying that that may be in question they don't know that for certain in general patients with myeloma should avoid NSAIDs if at all possible anyway so they definitely comment always preferred exactly and what it turns out is what we think is the co vid there's a Goldilocks phenomenon meaning you want just the right amount of immune system too little in the case of if you give things like NSAIDs ends has actually affect the immune system because they're anti-inflammatories and inflammatory cells are what our immune system is so if you take too many NSAIDs the concern is the virus can take root on the flipside an overactive immune system may not be ideal as well in fact one of the drugs that we're using in advanced kovat cases is a drug we use and people who get Carty therapy so the cytokine release syndrome that people are at risk from with Carty therapy if they get it it's basically when their system gets too much of a chemical called interleukin 6 and that really drives these high fevers and low blood pressures and we have a drug called totalism ab that blocked that so people get overactive cytokine release and Karki therapy we can shut it off with totalism ab it turns out the same chemical it's elevated in car keys in people who have kovat elevation that compound is correlated with a worse outcome and there was a paper released from China recently that twenty patients who were severely ill essentially all of them had massive improvement when he did in total ISM map now it's not ready to give to everyone and it's not clear that everyone needs it but it's another tool in our armamentarium for people get very sick yeah I thought I'd read the paper on that that was so interesting that's that's being listed because I have that myeloma connection with cytokine release so interesting I think just that the world is searching for solutions right now so it's fantastic should myeloma patients be proactively tested at their myeloma visits that they're there already if they think there might be some kind of symptom what do you suggest in terms of like what symptoms should patients watch for and things like that absolutely and this is great and the reality is I'll give you the answer today of what I say but it's going to change in the next 90 days because of the guidelines for testing our literally changing moment-to-moment and depending upon where you live the availability may be very different so obviously if you have any of the classic signs of kovat which are fevers shortness of breath dry cough you should be evaluated and tested my recommendation would be is to call your local physicians office or urgent care center and see if there's a way to be tested outside of an emergency room it's optimal to avoid emergency rooms if at all possible if you're not very sick obviously if you're having significant trouble breathing lethargic really sick then you have to go to the ER but if you generally feel well and you take your temperature it's a little bit up you have a little bit of a cough try to do this outside of an a hospital or clinic setting so you can do it in urgent care or in some of the drive-by centers that are being set up if you already at your physician's office and they're able to test you there is no downside to testing there's plenty of upside and much of this comes out of data that was looked at in the the province of Voe in Italy where they tested every and it turns out that even asymptomatic people have it and the benefit of knowing is that if you know you have it you'll avoid other people from getting sick but again the ability to test is going to be different from place to place and moment to moment so obviously if you have symptoms get tested if you're at a regular visit you can ask and if they have the availability to there's no downside to being tested yeah and it sounded like from some of that data that was coming out of Italy that you could have it for up to five days or something like that without having any symptoms so that's part of the issue is that when you don't know you're out and about and yeah causing our plumbing issues when you don't even know it and that's part of the reason we're seeing the steep rise is because it could be up to five days for some people to even longer until they have any symptoms and you know you know I think social distancing is really neat reading reaching appropriate levels now but unfortunately the last couple weeks it's taking a little bit of time for you know everyone to get on board with this so we still made people may have been infecting others so as as soon as there's more testing available um you know we should all be tested as soon as possible and actually someone had chimed in on a Facebook post about this Mount Sinai actually just published a paper of the infectious disease in microbiology group it's Mount Sinai developed the first antibody test for this so the testing that's currently being done is through what's called a PCR polymerase chain reaction and basically it looks for little bits of the virus and that's it it tells you have a little bit the virus none of the virus um but what this test that was just developed at Sinai and is going to be rolled out probably within the next week I was looking for antibodies and there's a lot of advantages of doing this on the antibodies can be detected uh even after only a few days of symptoms so it's a very efficacious test it also lets us know who's immune we know who's immune we can help work on developing vaccines and preventative strategies from that the other issue is once healthcare workers we know that someone has had it and is immune we can send them back to work to help others so this is a major step forward and we're very happy about it well we made that test right away yeah it was just developed yesterday they published the paper oh my gosh we're going to roll out as soon as this weekend which I mean that's one of the things you know some of the testing that's being done in clinical trials with a drug called run death severe which was used to treat Ebola in Nebraska most of the time trials like this take a decade to open up and this is being done in a matter of days and weeks and it you know through a horrible thing it's amazing to see the medical community and when I say the medical community I'm not just talking about the scientists nurses and doctors I mean even the people come in to clean the floor the people serve the food everyone is taking a risk they're all joining together along with the FDA to get therapies out as quickly as possible yeah amazing and stunning and so it's just wonderful that this is happening I know on the waiting period is that this test have any certain wait until my son got tested yesterday and it's like a five-day waiting trade before he knows so he's kind of just hunkering down before he knows when he has it or not yeah so we're speeding up all the tests this I think has a lesson a 24-hour turnaround but don't quote me on that because they're literally this was developed within the last week so you know getting it up to commercial grade is a little bit you know that is all being rushed and it'll be open within the next week or so potentially even by this weekend there's still a short turnaround but I think across the board every even the viral test where we're getting shorter and shorter turnarounds mm-hmm so you talked about some symptoms that are serious enough to go to the hospital so shortness of breath or being overtired seriously overtired are there other symptoms patients need to watch for does it happen quickly do you need to act quickly how much time do you have in doing it and then you talked about going to the ER but if you test positive and let's say you don't have serious symptoms they don't need to go to the hospital necessarily who should treat you should you go the local clinics should you call your myeloma doctor and go there should you know what what should patients do I think that one of the things we're all aware of is that there's a lot of unknown so the first thing I would say is when in doubt call if you have a temperature at home of 99.9 and you're not sure called um you know if you're feeling relatively well called doesn't matter if it's 2 o'clock in the morning we don't want people being stoic because what may be fine to wait at one point may be more urgent later on so close contact and you can call anyone you can call your myeloma doc your primary care doctor and we end up we may end up working together so someone called the other day who is quite a bit of ways and said where can I go get tested and I said you know your local doctor will know the answer he knows all the hospital's right around there I don't know all the hospitals in a small town in Tennessee so I think in general the symptoms don't have not been coming on as thunderclap like you're fine one minute not find the rest unfortunately most people experience the flu so I think it's somewhat similar where you start feeling a little bit unwell and all of a sudden you know over time symptoms get worse and worse and I think at the end of the day you know your own bodies if you know that something is really wrong you call if something is really really wrong that you can't catch your breath or your fever is 105 you know that's not necessarily time you can wait for a callback you may need to go to the ER but all else means it's just a little bit of a cough a little bit of a thievin you otherwise feel well call your local Urgent Care call your myeloma doc your primary care and we can all work together to find the best setting to be tested to avoid hospitalization if at all possible yeah great all right so what are the typical treatment for covered 19-4 of myeloma patient and is it that any different than normal population so um we've developed some algorithms here and we're trying to work them out because the data's changing moment our day by day so that IVIG drug which is unclear if it helps or hurts if your immunoglobulins are very low we may give you some IV I G what is a rising is a drug called hydroxychloroquine more commonly known as plaque window that appears to have some really good effects in people who have kovat 19 so depending you know if you come into the hospital and you're short of breath and you're acquiring oxygen we made up the ante and give you plaque window which can modulate the immune system the steps beyond that become a little more complicated in its case by case so there's if you have one of the things we're able to do here is measure those levels of il-6 and if you're starting to have more trouble breathing and your eye all six levels are high and clinically appropriate we can give tosyl is amad and we're even part of a about to open a clinical trial but have access potentially the compassionate use if needed there's a drug called run best of year from desafio is a drug that was designed to treat the Ebola virus previously it's available on limited access so for patients who are unfortunately very sick in the ICU that's an option and then the other options are kind of up in the air and case-by-case so some of the older HIV drugs Ratana beyond Lupino there may have some antiquing with that case-by-case Korakuen which is somewhat oxy chloroquine may also play a role unclear about steroids whether or not they help or don't again if you're having trouble breathing because there's so much inflammation along we may give steroids and approaching myeloma patients no steroids better than almost anyone on the planet but those are the main items we're using right now okay great and if somebody's being a local doctor and it can't access their myeloma specialist for some reason what are the other doctors need to do about a patient's myeloma when they're being treated for carbon 19 so that's an extremely important question I think that's saying that I'm glad you asked because it oftentimes falls by the wayside um what we're doing again is case by case for the majority of people who develop coded 19 we are stopping their therapy um now that may not be correct for everyone so what I would highly recommend is people don't take it upon themselves to stop but to reach out to their oncologist and myeloma specialist and discuss with them you know what's the risk and benefit from but for many patients we're holding the therapy to allow their immune system to kind of take care and part of managing the virus as much as possible have you had a lot of patients test positive in your myeloma clinic um we have not had many we have had a few that we've had to manage with this and that has been our general strategy yeah so although these are just such crazy times what can patients do to stay healthy or fit if they're using you know normal social distancing but I think people need to make sure that they're not socially isolating also like both physically and mentally do you have any recommendations about that lutely so the three general principles of life um eat well sleep well and get exercise apply whether you have Cova 19 or not myeloma or not those are three very important things from a physical standpoint so eating well as many of us are socially isolated um this is not a time to just eat chips on the couch um so healthy eating is really important as much as possible obviously within reason um if it's difficult to get some of the fresher things canned vegetables are oftentimes a better thing than having a box of donuts um so healthy eating is important sleep is very important everything is made better by good sleep and worse by no sleep so your sleep as best you can if you need something to help you sleep I'll reach out to your care team and we're happy to prescribe something to help people to get to sleep as our minds start to race when we lie down at night after watching a whole day's worth of craziness on the TV and exercise exercise is just a generally good thing physically immune wise etc there are many ways that even though we often don't exercise at home so what my wife and son have been doing along with our daughter is doing home yoga there's many stations on youtube or on the television to show you how to do home yoga and home exercise there's even some funny ones on YouTube which I wouldn't suggest where people put oil down on their kitchen floors and use it like a like a treadmill I wouldn't suggest that because you can slip and hurt yourself but there are many low and no impact ways to kind of keep things healthy the other thing you brought up which is something were hyper aware of and maybe not be optimizing is mental health mentally this takes an enormous toll on a group of people who are already facing a mental toll that I can't begin to imagine so you know doing what you can to keep your mental status up and your mental health up is crucial if you need medicine help it's there one of the things I highly suggest it's 20/20 FaceTime call people FaceTime with people if there's someone you haven't talked to for a while call them this is the time to make sure that we stay and we're all interconnected by our phones now's the time to use that to its maximum yield you normally recall your kids once a week call them once a day everyone's at home everyone has time on their hands right now except for their the people on the front lines take the time to call your loved ones call your friends engage with people there are many ways technology can help us yeah that's amazing great advice terrific advice well I'd like to transition some caller questions so we have time to bat if you have a question for dr. Vicktor please call 3 4 7 6 3 7 2 6 3 1 and then press 1 on your keypad and I'll be able to see if you have the question so let's see colors from 2 6 4 7 6 9 go ahead with your question hi Jenny is Jackie yellow great question how are you I'm foon we're doing fine and great answers from dr. Richter since I can no longer ask him the question about eating chips on the couch I'm going ask a little bit more about clinical trials I know that Bella and Bibi 2121 are close to approval are those trials that the FDA would be looking at I hope they're already fully accrued I think the you know even so it's complicated because both of those drugs or both of those treatments have multiple trials so all of the Bella trials are called dream there's dream one two three five six and and all of the B b21 are called karma karma one two three the main studies are accrued and we're just looking for follow-up I can't answer the question of is you know is the infection going to stop it stymie the one little piece of data that they need my guess is that it will not that at this phase where those drugs are where they're literally due to be approved within this year um hopefully within the next couple of months that it's simply a question of the final follow-up some patients the data and all the paperwork that needs submission to the FDA I know that all the companies are working very closely with the FDA to minimize any impact kovat will have about getting these drugs up and running that being said the one thing that I would think about is let's say they were both approved tomorrow bella is a drug that gets manufactured shipped and given in any office that can give infusions BB 2121 is a little more complicated it requires phoresis it requires manufacturing of the cells so even in normal conditions it may have taken a little bit of time to get that up and running but in speaking with the people at BMS Celgene they're still highly dedicated to getting this in the hands of patients as soon as is appropriate and if a patient were in the middle of a clinical trial I gathered that if they were diagnosed with Kove 819 that you would end up stopping treatment associated with that trial um it's a really great question um the answer is not necessarily it depends upon what the drug is how bad the infection is and the rules of the trial so what most trials have in the protocols is guidelines to say if something bad happens you can hold the drug but oftentimes it'll say if the drug has to be held beyond let's say four weeks on you can't go back on the drug the sponsor says okay so under normal circumstances let's say you're on a clinical trial you get a pneumonia and you're off for four weeks this study may say listen you've been off for four weeks we have to stop it I think in this setting with everything up in the air um the FDA has been really gracious about letting us know that we need to do what's in patient's best interest more so now than ever so case-by-case basis but I think that if the infection is mild and people get over it there's a good chance that we can get them back on study so I wouldn't just stop study drug but again this is really case by case thanks so much for your answers and I look forward the next time we see each other absolutely sir okay great okay we have many many questions so we'll ask everybody to limit their questions to just one we've color at three nine one six four three one go ahead with your question yeah hi this is art Lavis I previously was a patient of dr. Richter and I there's a lot of contradictory or morphus information about what how the disease can be copa90 it can make attracted and one of the studies said there one of the doctors said that the drug li the disease lingers in the air the virus lingers in the air can you would get Kovac 19 from breathing it in an environment we've been exposed to the virus in the air so I think you're asking the really important question and I would be lying if I could tell you exactly on what we know because I think you put it perfectly that the information is somewhat conflicting it is very amorphous um one of the things that we do know about kovat infection is that apparently the viral load matters and what that means is there are some diseases where the amount of virus in you doesn't really seem to mean too much you either have it or you don't pregnant or not but in kovat the amount you have seems to matter so if you are literally sitting right next to if you're living with somebody and you're literally around them all day long and get continual viral particles into you that is probably far worse than even if there's a small amount that you inhale that has been out there now again this is the data is changing daily I think that in general when people go out especially when you go out to markets grocery stores wearing masks is a great idea the surgical masks are just fine you don't necessarily need an n95 mask but I think you point out perfectly we don't have clear data and guidelines right now and as this moves on we may learn more so what I'm doing to protect myself and my patients is you go out you wear a mask but in general we know that people who get higher viral inoculum from being in close quarters with people seem to have worse outcome okay thank you a great question thank you so much for an ounce or two okay caller it to min Han Lexi three nine one six four three oh we just did that's sorry call her at four six eight eight five five two go ahead with your question hi Jenny this is Andy I got your mystery destination Alaska native oh I was supposed to be there today talking to you in person but I think I'm so much more valuable they want me in the building any way to go so my question is I'm reading a lot about different clinical trials are testing the effectiveness of different drugs just like you had said earlier in this show now are those drugs only being been through a clinical trial or are they being giving whether or not you're in a child and would you recommend if a my limitation does yaqoub in nineteen to try to make it to the research centers and stay with your community hospital all great questions so um many of these drugs are really are not very ubiquitous so if a drug has no real FDA approval it's really kind of hard to give so REM desapear is not readily available we can't just give it to people tow solution AB is is more available so we can make clinical decisions at the bedside and if we think the benefits outweigh the risks we can give it but again it's a more severe step hydroxychloroquine is drug Plaquenil there are probably many people listening and out there family members that are already on this drug so that drugs a lot more readily available and i think we're more willing to give that in a place where we just don't know the answers so when drugs are you know sitting in shelves that we have ready to go more of an inkling to give them some of them do need clinical trials but what's really great if some of the drug companies are opening up outside of trials compassionate use program so much in the same way that we have compassionate use programs from myeloma for example right now Balanta mab is available through compassionate use and expanded access programs even outside of a clinical trial same thing is being done with some of these drugs and was your last question again oh those bad right guys how to make it to a research center or go to my community hospital you know so it's really it's a complicated question um I think depending upon your symptoms it's you know obviously if someone is very very sick you need to go to your closest center because time to getting those supportive care meds the oxygen the cat-scan the IV fluid those are critical and those can be given anywhere I think that if you are otherwise feeling well or then it's this is a conversation you have with your care team because it's a great question if you live ten miles from your normal ER but 15 miles from your myeloma Center it's an easy decision if it's ten miles and 50 miles and you're not feeling well you shouldn't go down there so the majority of what we're doing can be administered at any Center so the default answer is closest but if you're feeling well it's a great question to ask your care team okay thank you very much and hopefully I get to see you soon I'm looking forward to it all righty bye-bye okay great thanks for me for your question okay I'm color eighth course but do you have a hard spot dr. Vicktor at the top of the hour or do you want to see a minute to my question oh that's a few more okay great okay great we have color at eight four seven five seven four eight go ahead we share a question why not director so you spoke about IVIG as a potential measure to prevent infection although I think he said for some patients it's recommended others it's not what about in Lhasa would that work for antiviral rates only antibacterial um so no acid it's a really great question so um you know we talked about the immune system and there's many many parts of it and I wish honcho was here who knows more about the immune system than any person on the planet you know in broad terms is the humoral and their cellular humoral the antibodies that IVIG helps with Neulasta health of the cellular immunity increases your white blood cell count it tends to help increase your neutrophils which tend to do more to fight off bacterial infections however with any virus you run the risk of a superimposed bacterial infection so it's not uncommon that people get something like the flu or Rhino virus and the doctors still put you on antibiotics because you got a superimposed bacterial infection so we are using any less than people who present with low musical counts or low white blood cell counts to make sure they don't get anything else but in and of itself as probably doesn't do too much against kovat but for somebody who's on maintenance therapy and is uh perpetually immunosuppressed do you think it's it's it's wise to get it preemptively neoteny it's a great question I mean the bigger question is if someone's on maintenance and otherwise in remission and is always neutropenic the question is should maintenance be held right now and again this is a question to ask your myeloma care cream for many people like this that need maintenance we know we can't stop it we do give them new Alaska uh but for people who have been in remission for years and otherwise fine I always come in with their ANC at 900 this may be the time to hold off a little bit thank you okay great question okay caller nine eight three six seven five seven hi Jenni hi dr. Richter it's Dana Holmes how are you guys today thanks so much talking with us it's just terrific really it's just them your knowledge is just so incredible thank you for that I was sold and I'm actually yeah and I are super excited to read that paper yesterday about your colleagues at I can with the that serum antibody titer essay because I honestly well just my observation that I this past influenza season may have actually masked a lot of this Cove in nineteen including in myeloma patients so it would be really great for us to be able to tease out if any of us actually had it so I'm looking forward to seeing that hit the the ordering supply chain yeah absolutely and you know this really and as opposed to just telling us the viruses there or not it lets us know who's immune it also means that workers don't necessarily have to be fiddling with the virus itself so it's more safety for the people who are in the text on the front lines of this early and you know if we know who's immune you know because part of the thing that kovat really makes it difficult is right now if you have an upper respiratory tract infection we don't know right so we don't want to start breaking out some of these big guns like totalism a brand that's where they have potential downsides if we know you already have antibodies and this is another infection so more ways that we can help avoid giving unnecessary risk to people always a big plus absolutely and I can honestly see this helping somewhere down the road of you know when when you know IVIG is actually pooled IgG so if perhaps some of these antibodies are going to find it into the IVIG supply someday for everybody to so that's really terrific you know there's another study that came out from France it's an on rent and a randomized trial that coupled as if from iesson with hydrochloric hydroxychloroquine yes thank you and it was really impressive I mean again it's and I'm not I wasn't sure if it was mild or moderate cases or severe cases but the most of those people who had the combo changed the PCR from positive to negative in just five days I mean that's like taking Tamiflu for crying out loud yeah I mean so the issue is because you can have this prodrome of no symptoms been to begin with those people may have converted to peace no negativity but that was a way course however hydroxychloroquine can may definitely improve this and is it's on mice and then z-pak that we always get yeah monetary properties so even though it's not fighting off a bacteria their anti-inflammatory properties of is it remaining which may help in terms of symptoms as well so yeah I think your point is really a great one we don't know did that hurry up to get people negative viremic or negative ionic anyway but it made them clinically better to get better and either way it's a way right well now can you you were hearing the term immunocompromised having a suppressed immune system and if one has it that there's obviously a higher risk for major complications from kovat and cancer patients are obviously included in this and so our myeloma patients and so we so we get that we know that the risk of complications is higher and likely contracting it is higher but what does it actually mean to be immunocompromised which biomarker metrics tell us our current immuno status which labs do we look at I mean I would imagine our labs can change daily so do we rely upon this to know our immune status at any given time is it prudent to do that or do we just err on the side of caution right now due to the very nature of having myeloma or smoldering myeloma in my case knowing our immune faction it function likely stinks and proceed just using the utmost caution if you continue to ask such great and now with some questions like this we're going to bar you from asking any further questions I know this is a great knowledge so yeah and the short answer is your last statement is perfect everyone should have exercise extreme caution at the end of the day the immune system is not one lab test it's not even two lab pets the majority of our immune cells and our immune function we don't check on a regular basis we don't check our NK so we don't check our dendritic cells our T regs we don't check all of the individual components the best we have is what our immune globulin and waters our white blood count and lymphocyte count one of the things that seems to have a negative impact on outcomes for kovat is lymphopenia al-hola not neutral for you but lymphopenia in the question I read that when people have lymphopenia gets sick with coded was it because the virus itself made them lymphopenia or did they have lymphopenia from other reasons like myeloma or their drugs and we don't know that answer so I think looking out to maximize an individual's lymphocyte count their neutrophil count and their immunoglobulins right now is probably to an advantage but what someone was talking to yesterday I introduced him to a term that I've never heard before that I'm going to steal from her she says well there's not this just immune compromised and immunocompetent there's a Muench allenge and she considered herself immune challenge not immune suppressed no there's shades of grey in there and because right know that we factor it every time I think right now is everything should are on the side of precaution good good thank you so much thank you so much for taking all my questions hi dr. Richter my question pertains to I recently started a regiment of if they need a clock Velcade index and specifically in order to minimize my visits to the office I was wondering if I were to suggest aligned myeloma specialists to pear mallero instead of the Velcade with the needed clocks would that be a safe pairing to suggest to have a discussion to in order to less frequently doctor's office I think it's a you know I think it's an absolutely phenomenal question to have the reality is we have very little data on that combination so the Bellini trial which is the big registration trial we actually know very well the risks and benefits of Velcade with Vanetta quacks we know a little bit less about an in-law and Vanetta quacks that being said I think it's a great idea to have that conversation um there is a little bit of side effect overlap but I think the dosing can be done in such a way to make that safe now again there's there's facets of your disease that he or she may know far better than I but I think it's an extremely reasonable thing to reach out to them and say listen I want to minimize my visit is there any way we can switch it over tune in tomorrow and talk about so I think it's a great idea great I will do that thank you so much according to that great great question okay caller eight six nine zero eight zero six six go ahead with your question yes hello dr. Richter and thank you Jenny my husband is on Revlimid and my question is the components of this drug made in China and it will it affect his ability to continue getting the the Revlimid really great question is something a lot of people are asking I can tell you that no first of all the one thing about China is that in the last 24 48 hours have been no new cases last time and looked at the data from China from gube a Province in Wuhan where this originated so the fact that on the down slope is actually a good sign globally about the light at the end of the tunnel of all this that aside I can tell you that the people at BMS sojung in particular who manufacture a Revlimid have literally been even though people at home they're literally on the phone non-stop and we've been in contact with them making sure that people have continued supply of drugs so I would not be concerned about that at the moment I think that there are a lot of ways that we're able to get over this um in a pinch and I mean in a real pinch there's alternate dosing strategies where Revlimid could even be taken every other day instead of every day um but I I doubt we're gonna have to come to that because the companies have been really good about ensuring that drugs going to be available thank you so much dr. Baker okay great great question okay caller two nine six seven zero two zero go ahead with your question yes thank you dr. Vicktor and thank you thank you Jenny for doing this it's a very good thing as Dennis crow I'm a veterinarian actually and my wife has multiple myeloma and she has it's fairly significantly but we're waiting for the Carty trial at this time she is HUD her cells harvested and so we're about four or five weeks now from probably getting those cells should you you think we could one go ahead with that that's the number one thing - I've heard a lot and been reading a lot about just simple things like elderberry and how it may also be helpful in the immune system related and then the third hyperbaric oxygen has been used during the Spanish flu in 1918 and it was used successfully this was hyperbaric air only with air pressure and so I know those those are successfully treated for patients that had the Spanish flu and we're near death you know cyanotic unconscious taking their last breaths and when they got in the chamber they were able to then survive actually truly survive after several treatments can you come in on those three things than for me please whole lot there's Kartik Cartier's it is difficult so this is something obviously if you get if she's in line for a cartoon or self-corrected she's at one of the top myeloma centers so I can assure you whatever the decision that they decide on I've no doubt it's the correct one um you know a lot of this depends upon the status of their hospital so if it's a hospital that is being overrun by kovat that changes the dynamic how well controlled is your wife's disease and what options they have so let's say we have all the freedom in the world and this is an earlier phase relapse and the bridging therapy she's on is working perfectly it may be the better part of valor to delay the infusion and keep her on the bridging therapy until such time as it becomes safer if this is a more advanced canary or where there are no real good options and they can still give it and I don't think there's a contraindication to going ahead however if an alternative can be found that may be optimal as far as she's not only ignorant oh she's got any current bridging therapy and all right now the doctor thought that we would be able to move right along from where she was to you know be getting into the car T so getting ourselves so she's not in a bridging therapy at this time at all winds are said well we don't know but that's a you know that's a good that means that they're confident that even without therapy on that time things will hold steady so again I'm so unfortunate Lee this is a study by study question and if you're getting a car team without you don't have to tell me where she's going I'm sure the doctors there have a well clear plan for this thank you for yeah elderberry and hyperbaric oxygen I've seen those floating around um we just don't know you know elderberry probably has some immune modulating effects unclear how much it helps this may be along the same lines as to Newark Ackerman that a lot of people with myeloma take where it may have some positive effect but we don't know fully how much so that's going to be a tough one and hyperbaric oxygen is less available now because we just fewer indications for it um and unclear if the same mechanism by which it held off the flu will help um the one thing I would say as a veterinarian I would ask you one of the things I've seen floating around is a discussion that there are a number of ventilators that are being that are available for large animals like pigs and elephants and giraffes that may be repurposed to use for people I don't know if you can comment on that oh sure I could others I'm with a basically Association called American College of Veterinary critical care emergency and critical care in that College we're all basically diplomates in that College we have donated if you will you know lent if you will our ventilators to many many different institutions all across the country so these are you know just good ventilators that are just having all the different way ways of ventilating mostly small animal patients you know it'd be cats and dogs that are critically ill and that actually gets me a question we're still opening in our centers and so we're not you know ventilating our patients you know because those patients have those ventilators went to the human hospitals you know you guys need way more than we do but what about the transfer of kovat 19 unpaid pets hair you know it's mean it's like almost like an antigen like a cardboard box you know if it's able to cost people you look often get the viral particles on pets hair I think don't you think that our our veterinarians that are in critically caring and for these patients should also be almost protected like you would an ICU doc as well in the m95 mask well n95 are really only indicated this time for aerosolizing procedures so if you're doing any procedure on animal that's aerosolizing potentially aerosolizing things and n95 masks with goggles is absolutely needed for routine care faceshield surgical masks and gloves gown should absolutely suffice all right okay roll it's good to let have a chance to talk with you thank you so much pleasure sir thank you so much for your great questions we have a hard stop on the software at 1:30 so we'll just keep going if you don't mind with the few questions color it to for noise because i if we just do together here i had a call at 3:00 sure sure sure oh yes sorry okay go ahead is your question two more questions on hi thank you Jenny and dr. Richter I am possibly coming close to relapse the numbers were rising and I had a thought on my zygote zygomatic arch and so my doctor increased went back to my old frequency on pomalyst and i can't think of anything i was so surprised you did that dr. merciless okay promise hi Perla and we're going to go that route for until further notice but I am I went and saw the radiation oncologist and they're recommending me having radiation to that area on my left side it's the corner of my eye and that arch area there now that's supposed to start next month and then of course I'll start stopped infusion but what is this radiation going to do to my system and with the virus will inhibit it caused me to be more susceptible to it and no in general not oh sorry I know but I have to go in every day for two weeks but it's in a separate building and this is way off talking about protein him inhibitors someone has talked about them doing some studies on it and the co vid virus and I know there's tons of like you said medications out there we don't know yet but I'm just throwing that out there anything about protein inhibitors and the koba's virus do you mean produce um inhibitors yes Oh like car salesmen we just don't know and yet um about that in terms of the way in a weird way they're going to protect me unclear um you know again there are immune modulating drugs you know strokes like pomalyst and kyprolis it's not that they kill every immune so they activate others so there may be some reactive nature it's really case-by-case and unfortunately just don't have enough information yet to say one way or the other the radiation itself to the zygomatic arch depending upon the size is usually toxic because it's not a very large area um the other you know your concern about going back and forth twice a day um that's you know that we have once a day is a real concern so if you just started on KPD and the radiation is prepared plan for a little bit of time but your symptoms are getting better because it's shrinking you may be able to hold off on the other hand radiation and kyprolis is generally a safe thing it's the radiation in pomalidomide that's actually more of a concern because yeah do together can give you more lowered blood counts um so you know again well it would be different in use there's no doubt about that they've already told me that the other question that you may ask your radiation oncologist is is there a way to do this in a fewer number of fractions so depending upon the area of radiation and the need sometimes you need 10 fractions so 10 visits sometimes you can do it in five sometimes you can do it in one so I would reach out to your radiation oncologist today understanding that you plan this I don't know if they told you five or ten sessions I think it can I'm not too sure because she said like two weeks so I'm assuming you can because I had it you and I guess before and it's going to be half as much as what I had before I think she said 24 use that makes sense it's usually gray it's usually so if they do ten sessions they often do 300 centigrade times 10 to get 30 or she may be giving 20 240 a day times tend to give you a total of 24 but depending upon the type of radiation oncology sometimes they can do a higher dose in fewer fractions depending upon where the area is so you should ask if they can do it in fewer fractions yeah well they have to be careful about my eye and you know they told me about that but that spot was there a year ago from my PET scan and my numbers were going up to this a little bit I mean I'm still in the safe zone but we are seeing changes so all they did was just increased the frequency a little bit back to what it used to be they were trying to step back because in my white cell count so right now it's holding okay that's why we should abandon it right well thank you very much and same question oh all right okay I'm sorry we have one last question nine three five six five one five and then we need achill no go ahead with your question hello yep we can hear you oh I'm sorry um I had a stem cell transplant University in Maryland and after that about three months after that I had PCP pneumonia I had bronchitis on and off so the doctor said to me you know I think it'd be a good idea to get the ID ID so I've been doing that for the past five months and it has brought up my ID ID number my IG am i up GM or just very low but it did it in boost and I haven't had bronchitis I've been doing really well my question is do i discontinued going for the IVIG because of the Jeopardy it would put me in with possibly going to the hospital to get the infusion infusions about five hours so do I know which way to go so if you're at the University of Maryland you're probably either seeing a Charlotte Rosaura Medical Group no actually dr. Rappaport and he has sent me to GBMC gradable Medical Center and my daughter there is dr. element oh great great there yeah they're phenomenal group what I can tell you is that these are you know unfortunately the answer it's a personal decision I can tell you that if you've been not having infections and your IgG is essentially normal risk-benefit I think that it's not unreasonable to hold it um but understand that you had PCP pneumonia which is a you know still something we don't see that often you know you may be someone who needs it more than others so really I think your question is a great one and this is something that really should be directed to the team and Maryland and they'll be able to have a discussion specifically for you what are the risk benefits what if if all of the progress I have made with the IVIG if I were to miss one or two of the infusion then I lose all the progress I've made no in general you don't um but but I would emphasize not just making the decision on your own because there are other there are other little things that may be relatively insignificant to you but the team in Maryland will expertly say well you know because of this level or because of that clinical feature you should really continue or they may say you know your IgG is normal you can hold it so you're working with a great team I know they will guide you the right way okay thank you both so very my grant really free oh thank you so much thanks for your question thanks everybody for all your amazing questions and dr. Richards thank you so much they've been just an outstanding show unbelievable show with so much information so we will post the show later it speaks to the need to see my little specialist if you haven't captured that point by now I just want to comment on a few other things that we have in terms of support so in terms of staying fit like what you were saying dr. Richter earlier about staying fit and keeping moving and we have a local firm a little web program that we're running and it's all virtual and you can join that and you can log your minutes and chat with other people who are doing the same thing and coming up with creative ways to exercise at home we have a myeloma coach program that you can reach out to and find out myeloma coach to answer some of the simple questions to maybe offload some of those questions from your doctor and then we have a health tree platform and since everyone's at home they can fill out their health tree profile because we will probably be running a kovin 19 study inside of health tree so you can get all your information in there now but dr. Richard Richter thank you so much for your time my pleasure thank you so much for everything you do we would really do this really really unbelievable your expertise and your willingness to share it so thank you so much everyone for listening to my mama crowd radio and if I get a tune in next time to learn more about the latest scandal animal research and what it means for you you you [Music]