All About Velcade (Bortezomib)- Updated 2025

All About Velcade (Bortezomib)

So Velcade, also called bortezomib, is a proteasome inhibitor that's used in the treatment of multiple myeloma. It's one of the main classes of drugs that we use in the treatment of multiple myeloma. Velcade or bortezomib is a first generation proteasome inhibitor and is considered a reversible proteasome inhibitor. In 2003, Velcade for IV administration was granted accelerated FDA approval. In 2012, Velcade for subcutaneous administration was granted FDA approval.

How do proteasome inhibitors work?

Proteasome inhibitors work by inhibiting proteasomes. Proteasomes are intracellular machinery that is intended to degrade intracellular proteins basically to allow for the normal function of a cell to remove the proteins that are not desirable. That's important for maintaining a cell's integrity. And proteasome inhibitors work by preventing that. So there's an accumulation of junk products. And this ultimately leads to cell death. And this cell death in the case of multiple myeloma, is what is desirable because we were intending to kill the myeloma cell. To learn more about the class of anti myeloma treatments known as proteasome inhibitors. Make sure you watch the lesson on proteasome inhibitors in HealthTree University's Classes of drugs course.

What are the indications for Velcade (bortezomib)?

Velcade or bortezomib is used in the treatment of newly diagnosed multiple myeloma as well as relapsed refractory multiple myeloma, and has been explored in numerous combination and continues to be a very front line favorable option, as well as option for later, lines of therapy.

How is Velcade (bortezomib) used as a combination therapy in newly diagnosed multiple myeloma?

Velcade has been a very favored agent for, front line, newly diagnosed multiple myeloma for a number of years. In the triplets era, supported by the SWOG S0777 study, it was used in combination with lenalidomide, also known as Revlimid with dexamethasone, and nowadays the era of the quadruplets. It's used in, different ways with the Griffin or Perseus data. We've seen that Velcade has been used as a, four drug combination with dexamethasone, daratumumab, and then lenalidomide, also called Revlimid. And then with recent data just from earlier 2024, we've seen it used in combination with isatuximab, dexamethasone, lenalidomide and Revlimid. And so it has continued to be a very, potent staple for our, front line options.

How can Velcade (bortezomib) be used in relapsed or refractory multiple myeloma?

Velcade has been used for different relapsed refractory scenarios and it's been looked at in several different trials. In general if someone is relapsed refractory with most recently having been on Velcade, it's not a favorable option. But if someone has not been on it before or if there's been a great period of time since they had the original exposure, it's a reasonable combination to try, some of the most notable are, the combination of daratumumab, Velcade and Dexamethasone. And then there are others as well. The combination of selinexor, Velcade and dexamethasone was supported by the Boston trial and is also a viable option for relapsed refractory multiple myeloma. According to the National Comprehensive Cancer Network's treatment guidelines, the following combinations can be considered for the treatment of multiple myeloma.

Velcade is used in the following combinations. As initial therapy for patients who are candidates for transplant. Velcade is used in the following combinations as a maintenance therapy. Velcade is using the following combination as initial therapy for patients who are not candidates for transplant. Velcade is also used for patients with previously treated myeloma in the following combinations.

How and where is Velcade administered?

Velcade is administered nowadays subcutaneously. It was originally studied as an intravenous drug and technically can be given that way, but it has a much higher rate of neuropathy and other side effects. And so the subcutaneous route of administration is really the preferable way for it to be given to patients. Typically it's given in the stomach. So an area of the skin is pinched off around the abdomen, and that site is rotated to prevent local reactions from occurring and accumulating. It can also be given in the thigh, if the abdomen is not preferred.

What is the FDA approved dose and schedule? How is it dosed in the typical practice?

It's, approved at a typical dose of 1.3mg/m² of body surface area. And by most clinical trials has been supported for use twice weekly on days one, four, eight, 11, and so on. To be clear, though, there are several clinical trials that have looked at different dosing schemes and in the real world this is adjusted even further. What we've seen with real world data and there's been a movement for this, with support is to been to just use once weekly Velcade. That seems to reduce the incidence of side effects, including neuropathy, while still maintaining excellent efficacy. Once weekly Velcade is administered on days one, eight, 22 and 29 of each month, with a one week break between days eight and 22.

How can the dose of Velcade be modified for patients who are frail?

In general, Velcade, like many other drugs, are adjusted for tolerability for the sake of the patient. And so if someone cannot tolerate the 1.3mg/m square dosing, it can be reduced to 1.1mg/m², 1.0mg/m². All the way down to about 0.7mg/m². There is a paper that has been published several years ago with adjustment, suggestions. But ultimately it's important to speak to your physician for that conversation because they will adjust it based on your particular scenario needs. Dr. Palumbo, a member of the International Myeloma Working Group, provides a helpful table for dose adjustments. Table one provides guidelines for the dose level to be used based on the patient's characteristics. If the patient has no risk factors, they will use dose level zero. Patients with one risk factor made just the dose to the level one. Patients with more than one risk factor may consider starting at dose level two. Table two describes the dose and schedule at each dose level. It is important to note that if you are on dialysis, your doctor will administer it after the dialysis procedure.

What are the main side effects of Velcade?

The most famous side effect that that's associated with Velcade use is neuropathy. And that's a tingling or numbness that occurs typically in the toes first can extend upwards from the leg. And also the fingertips. And it's something that most prescribers will ask about pretty much at every visit. If someone having pain or numbness in their feet are they having trouble buttoning buttons? That is the most, prominent side effect that we, we worry about. If someone does start to experience neuropathy, we often talk about dose reduction, dose interruption. And then there are other options to management as well, such as gabapentin or pregabalin or duloxetine. And if the neuropathy becomes something that is more prominent, something that is of higher grade, as we would say, then sometimes it needs to be stopped altogether or not pursued again.

Other associated side effects with Velcade use include, fatigue, diarrhea, low blood counts, rarely alterations to kidney and liver function, and all of those are things that patients physician would be looking for, watching for, and monitoring. It can also cause styes in a select number of patients. Somewhere around 5 to 10% of patients can get a stye or collision along the eye. And if that occurs, we will often refer to ophthalmology at an abundance of caution. But typically, warm compresses. And then sometimes dose reduction and dose interruption will help resolve that for patients.

What is the “air sandwich” technique?

The bubble sandwich with Velcade. It refers to kind of a trick by nursing that they will allow a little bit of air into the syringe, then the drug, and then a little bit more air to where then when it is actually administered to the patient, it softens the impact of that and helps diffuse a little bit of the injection. So where it might be very concentrated to a little bit less concentrated, that increases the tolerability locally for the Velcade. Typically Velcade is given over a course of a couple of minutes. But by experience, the bubble sandwich is more beneficial than the speed per se.

Serious side effects that have been reported with Velcade include heart problems, lung disorders, liver damage, tumor lysis syndrome, posterior reversible encephalopathy syndrome. If you are taking Velcade in combination with other anti myeloma agents, you may experience different side effects. Let your doctor know if you are taking medication for diabetes as Velcade can affect your blood glucose levels. Your doctor may ask you to closely monitor your blood glucose levels, and may adjust the dose of your diabetes medicine while you are being treated with Velcade.

What prophylactic medication should be prescribed when taking Velcade? Why are these prescribed, and what is the dose?

One medication that we prescribe almost universally is acyclovir. And we do that for shingles prophylaxis. To prevent shingles. It also more broadly helps other infections caused by herpes. Very de viruses. The typical dose for that is 400mg given twice daily. But I should note that that is adjusted based on the patient's kidney function. And so it could be actually much lower than that standard dose.

In general with a lot of these drugs that affect people's immune systems in any sort of way, it allows the emergence of shingles to occur or herpes zoster. And so in giving it preventive medication, we've been able to show that it has reduced incidence.

If someone gets a shingles vaccine, will they still need prophylactic medication for Velcade?

In general we do recommend that people receive the shingles vaccinations shingrix and zoster vax. But typically if they are still able to take acyclovir and are willing to do so, we still recommend that they do so as well. Because even apart from the specific shingles efficacy, there are other herpes everyday viruses that are treated by that.

Are there any premedications you need to take before a Velcade injection?

While not absolutely necessary, typically when people start, they will be given Tylenol and Benadryl and that can be peeled off as people's tolerance increases to the medication.

What is the difference between Velcade and bortezomib?

Velcade and bortezomib are the same drug. The brand name was Velcade, the generic name was bortezomib. And originally we only had that brand name, but we also now have the generic bortezomib as well. So we will use these names interchangeably. In general with most regimens patients will see the V there. So dara-Vd referring to the Velcade. But again the generic name is bortezomib. It's the same with one regimen. We will see the bor in it and that side bor d, but in all the other ones, wherever there is a V seen, it's a good bet that that's Velcade. That's being discussed.

Velcade is an excellent drug overall. It is tried and true for multiple myeloma. Continues to be a staple for myeloma care.