Initial treatment of multiple myeloma depends on the patient’s own characteristics, such as eligibility for autologous hematopoietic stem cell transplantation transplantation, the patient’s age and the presence of comorbidities. Younger patients Induction therapy Patients younger than 65 years of age with no comorbidities are usually considered appropriate for high-dose chemotherapy and for stem cell transplantation. Three to six courses of induction therapy are recommended prior to autologous hematopoietic stem cell therapy. The goal of induction therapy is to minimize tumor load prior to stem cell collection and transplantation. Nowadays, induction remission therapy is based on novel drugs, the application of which does not jeopardize hematopoietic stem cell collection and is supposed to be used. Some options are effective and the efficacy and safety data of most commonly used drugs are detailed in Table 1. the most effective combination therapies are proteasome inhibitors plus acylmidine or chemotherapy. As induction therapy prior to autologous stem cell transplantation, bortezomib + thalidomide + dexamethasone (VTD) regimen combination chemotherapy is superior to thalidomide + dexamethasone (TD) regimen chemotherapy. 3-year PFS was 68% for VTD regimen and 56% for TD regimen (P=0.005), but OS was similar (86% vs. 84%). Recently, bortezomib + adriamycin + dexamethasone (PAD) has shown to be another effective induction regimen. The efficacy of the PAD regimen chemotherapy followed by autologous HSCT and maintained with bortezomib has been shown to be superior to the (VAD) regimen followed by autologous stem cell transplantation and maintained with thalidomide, with median PFS of 35 and 28 months, respectively (P=0.002). In a multivariate analysis, PAD regimen treatment greatly reduced mortality (HR 0.77; P=0.049). In terms of PFS and OS, the PAD regimen benefited patients more than the VAD regimen, and there was also a significant benefit in the high-risk group of patients exhibiting creatinine elevations greater than 2 mg/dl and with chromosome 17p13 deletion. The efficacy of VRD as an induction regimen was demonstrated. In phase 1-2 studies, 100% of patients achieved at least PR. after a median follow-up time of 21 months, PFS and OS were 75% and 97%, respectively, when evaluated at 18 months with or without combined transplantation. The VCD regimen can also be used prior to transplantation therapy. response rates were found to be faster in the phase II study of VCD therapy. The CR rate was 46% in 28 patients who completed 4 courses of treatment. All patients had a very successful stem cell collection process. 23 patients underwent hematopoietic stem cell transplantation with a CR/nCR rate of approximately 70%. Thus the VCD protocol resulted in a rapid response rate. In the phase 2 study, the VDCR regimen also appeared to be an optional remission-inducing treatment option. It had a CR rate of 25% and a VGPR rate of 58%. However, three-drug combination regimens such as VDR, VCD, had better tolerability with 1-year PFS of 86%, 83% and 100% for all three, respectively. Based on this study, VDR and VCD regimens should be preferred for treatment in clinical work. Newer complexes are currently under investigation, such as the proteasome inhibitor, carfilzomib. Preliminary studies on carfilzomib combined with lenalidomide and dexamethasone (CRd) as an induction regimen are promising because of the improved response rate during treatment (42% for strict CR) and a 2-year PFS rate of 92%. Consolidation and maintenance therapy Consolidation (2-4 courses of therapy after induction) and maintenance (continued therapy until progression) therapy after hematopoietic stem cell transplantation can improve prognosis. Re-autologous HSCT may be one of the strategies to prolong PFS, although the advantage in OS was only demonstrated in 2 trials. The effectiveness of novel agents in sequential autologous HSCT therapy highlights the problem. Nowadays, consolidation regimens that include new drugs are recommended in patients who do not achieve VGPR. In one study, the VTD regimen consolidation therapy was used in patients who achieved VGPR after two ASCTs and the CR rate increased from 15% to 49%. A randomized survey study showed that CR/nCR increased from 63% to 73% with VTD used for consolidation after consecutive ASCTs, but 3-year PSF was only slightly improved with thalidomide + dexamethasone consolidation compared to 3-year PSF (60% vs. 48%). The choice of lenalidomide + prednisone as a consolidation regimen after dual ASCT was the better choice, increasing the CR rate from 38% to 66%. Several studies evaluating thalidomide in maintenance therapy after ASCT have found it to improve response rates, PSF, and OS. however, grade 3-4 peripheral neuropathy (17% 19%) is a major complication, resulting in discontinuation in approximately 52%. In a recent randomized study, lenalidomide maintenance after ASCT was shown to reduce the risk of progression. One study also showed improved survival in patients maintained with lenalidomide compared to those without maintenance therapy. Second primary tumors (SPMs) may develop with prolonged lenalidomide use, however, the benefits of this treatment regimen far outweigh the increased risk of SPMs. Less information is available on the effectiveness of bortezomib maintenance therapy. In one study in which randomly selected patients were treated with induction with PAD or VAD regimens and maintenance with bortezomib or thalidomide after ASCT, the CR/nCR rate increased from 31% to 49% in the bortezomib group and reduced the risk of progression. However, no randomized maintenance therapy was planned in this study.