Proteasome Inhibitor — Myeloma Pregnancy: Contraindicated — teratogenic; effective contraception required (male patients must use contraception if partner of childbearing potential)

Bortezomib

Brand names: Velcade

Adult dose

Dose: 1.3 mg/m²

Route: SC (preferred) or IV bolus

Frequency: Days 1, 4, 8, 11 of each 21-day cycle (standard); or days 1, 8, 15, 22 of 35-day cycle (weekly)

Max: 1.3 mg/m² per dose

Used in newly diagnosed multiple myeloma (VRd, VCD, VMP regimens), relapsed/refractory myeloma, and mantle cell lymphoma. SC administration preferred — significantly reduces peripheral neuropathy vs IV.

Paediatric dose

Dose: Seek specialist opinion mg/m²/kg

Route: SC / IV

Frequency: Per specialist haematology protocol

Max: Not established in children

No standard paediatric dose — specialist paediatric oncology use only

Dose adjustments

Renal

No dose adjustment required (including dialysis patients)

Hepatic

Reduce starting dose to 0.7 mg/m² in moderate-severe hepatic impairment

Paediatric weight-based calculator

Patient weight (kg)

No standard paediatric dose — specialist paediatric oncology use only

Clinical pearls

SC administration preferred over IV — APEX trial sub-analysis and SPA study: equivalent efficacy with significantly less peripheral neuropathy (SC: 24% grade ≥2 vs IV: 41%)
Peripheral neuropathy is dose-limiting — reduce dose or switch to weekly schedule if grade ≥2 neuropathy develops
Herpes zoster (shingles) prophylaxis is mandatory — aciclovir 400 mg BD or valaciclovir 500 mg OD during treatment
Neurotoxicity monitoring: assess before each cycle using validated neuropathy scale; dose reduction algorithm in SPC
VRd (bortezomib + lenalidomide + dexamethasone) is standard first-line triplet in transplant-eligible and ineligible myeloma
Mantle cell lymphoma: bortezomib used in relapsed/refractory disease (PINNACLE trial)

Contraindications

Hypersensitivity to bortezomib, boron, or mannitol
Intrathecal administration (fatal if given IT)

Side effects

Peripheral neuropathy (dose-limiting — numbness, neuropathic pain)
Thrombocytopenia
Anaemia
Neutropenia
Fatigue
Nausea
Diarrhoea
Herpes zoster reactivation
Orthostatic hypotension

Interactions

CYP3A4 inhibitors/inducers — may affect bortezomib exposure
Antidiabetic drugs — hypoglycaemia or hyperglycaemia risk

Monitoring

FBC (before each cycle)
Peripheral neuropathy assessment
Blood pressure (orthostatic)
Blood glucose
Herpes zoster surveillance

Reference: BNFc; BNF 90; SPA Study (Moreau et al. Lancet Oncol 2011); NICE TA311; NICE TA573; BSH Myeloma Guidelines 2017. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways