Management Algorithms for Relapsed/Refractory AL Amyloidosis
Authored by Rajshekhar Chakraborty, published on 2026-04-22 21:19:55.0
The algorithm broadly reflects contemporary relapsed/refractory AL amyloidosis principles: response-adapted switching based on hematologic depth/organ response and selection of subsequent therapy informed by plasma-cell biology (e.g., t(11;14)). However, it leans heavily toward investigational BCMA-targeted approaches and fixed-duration concepts that are not yet standard-of-care in AL and are supported mainly by early-phase/indirect myeloma evidence. The core switch triggers using hematologic response categories and dFLC-based relapse thresholds are generally consistent with major consensus/guideline statements, though specific timing cutoffs (1/3/6 months) can vary by guideline and patient context.
Relapsed/Refractory AL Amyloidosis after Frontline Dara-CyBorD
Indications for switching therapy
• 2 mg/dL as trigger for initiation of new clone-directed Rx
t(11;14)-positive
Treatment options (t(11;14)-positive)
Preferred: BCMA BsAb* [off-label or clinical trial] Bcl2 inhibitor [off-label or clinical trial] BCMA CAR T [clinical trial] Alternative/Less Preferred: ASCT BCMA ADC IMiDs [Pom preferred over Len]
t(11;14)-negative or unknown
Treatment options (t(11;14)-negative or unknown)
Preferred: BCMA BsAb* [off-label or clinical trial] BCMA CAR T [clinical trial] Alternative/Less Preferred: ASCT BCMA ADC IMiDs [Pom preferred over Len]