Elderly patients Induction therapy Many European countries consider ASCT to be inappropriate for patients older than 65 years, but according to scientific studies, the biological age of each individual does not always match the actual age. Low-intensity ASCT can be an effective treatment for elderly patients with multiple myeloma who have good underlying conditions and whose biological age is less than their actual age. The efficacy of bortezomib induction before transplantation and lenalidomide consolidation/maintenance after transplantation was evaluated in a phase II clinical trial in patients 65-75 years of age treated with low-intensity ASCT. 2 year PFS was 69% and 2 year OS was 86%. The combination therapy containing the new drug is indicated for patients whose underlying conditions are not suitable for ASCT. In a clinical meta-analysis of 1,685 patients, the MPT regimen was shown to be superior to the MP regimen, with the MPT regimen extending median PFS by 5.4 months and OS by 6.6 months compared to the MP regimen. In a phase III study comparing VMP with MP, VMP significantly increased CR rates (from 4% to 30%), time to progression (TTP) from 16 to 23 months, and OS from 43 to 56 months. Changing the bortezomib dosing schedule from once a week to twice a week allowed for better patient tolerability without compromising efficacy. MPT and VMP are currently considered the standard regimens in Europe for the treatment of elderly patients. In addition to these two regimens, other different treatments are available. For example, a phase III study evaluated the role of thalidomide in combination with alkylating agents and steroid hormones, respectively, cyclophosphamide and dexamethasone reduction regimens (CTDa). Despite having a better response rate, there was no significant difference in median PFS and OS between CTDa and MP. This phase III study also compared lenalidomide plus high-dose dexamethasone (RD) and lenalidomide plus low-dose dexamethasone (Rd) regimens for the treatment of patients with primary multiple myeloma. rd significantly prolonged 1-year OS compared with RD (96% vs. 87%). Consolidation and maintenance therapy New drug-based consolidation and maintenance therapy may also be used in older patients. In a recent phase III investigational study comparing marfalan + lenalidomide + prednisone induction followed by lenalidomide maintenance (MPR-R) with MPR and MP. MPR-R reduced the risk of progression compared with MPR (HR 0.49). the CR rate was 10% for MPR-R and 3% for both MPR and MP. MPR-R significantly prolonged median PFS (31, 14, 13 months for all three, respectively). 14, 13 months). The efficacy of bortezomib + thalidomide (VT) as a maintenance treatment regimen was evaluated in two trials. In the Spanish study, comparing VT with the VP regimen, 38 months from the start of maintenance, both VT and VP regimens improved CR rates (up to 46% for VT and 39% for VP), and median PFS was prolonged with VT compared to VP (69% vs. 50%). In the Italian study, comparing VT maintenance after VMPT induction therapy with patients without maintenance therapy after VMT induction, after a median follow-up time of 54 months, VMPT-VT had a significantly longer median PFS than VMP (35 months vs. 25 months) and a higher 5-year OS rate than VMP (61% vs. 51%). maintenance therapy with the VT regimen was better tolerated, with MPR-R and VMPT-R have better efficacy in patients aged 65-75 years, and this intense chemotherapy is not indicated in patients older than 75 years. Elderly patients with poor underlying conditions Patients older than 75 years of age or with poor underlying conditions are prone to adverse events. In such cases, reduced toxicity therapy as well as appropriate dose reduction therapy with standard MPT and VMP is acceptable. The two-drug combination is the best option for frail patients, and a phase III trial showed the same efficacy of VD as VTD and VMP. The median PFS was 14, 15 and 17 months, respectively. Lenalidomide plus low-dose dexamethasone (Rd) is also an appropriate regimen for frail patients. In fact, Rd was better tolerated than RD, with 2-year OS of 87% and 75% for both, respectively.