XPO1 (Exportin-1) Inhibitor Pregnancy: Contraindicated — embryotoxic; effective contraception during and for 1 week after treatment

Selinexor

Brand names: Nexpovio

Adult dose

Dose: Multiple myeloma: 80 mg once weekly (with bortezomib + dexamethasone — SVd regimen) or 100 mg once weekly (with dexamethasone — Sd); DLBCL: 60 mg twice weekly

Route: Oral

Frequency: Weekly (myeloma) or twice weekly (DLBCL)

Max: 200 mg/week

Pentarefactory myeloma (≥4 prior regimens); SVd regimen preferred; take with food to reduce nausea; antiemetic prophylaxis mandatory

Paediatric dose

Dose: Not established N/A/kg

Route: N/A

Frequency: N/A

Max: N/A

Not licensed in paediatrics

Dose adjustments

Renal

CrCl 15-59 mL/min: reduce dose by 25%; CrCl <15 mL/min: avoid

Hepatic

Mild: no adjustment; moderate-severe: avoid — insufficient data

Paediatric weight-based calculator

Patient weight (kg)

Not licensed in paediatrics

Clinical pearls

BOSTON trial (Grosicki et al. NEJM 2020): once-weekly selinexor + bortezomib + dexamethasone (SVd) improved PFS vs twice-weekly bortezomib + dexamethasone (Vd) in R/R myeloma (13.9 vs 9.5 months)
Novel mechanism: XPO1 (exportin-1/CRM1) exports tumour suppressor proteins and oncoprotein mRNAs from nucleus — selinexor blocks this, restoring nuclear tumour suppressor activity and halting myeloma growth
MHRA 2021 approved; NICE TA680 for R/R multiple myeloma ≥4 prior regimens; hyponatraemia is common (30-40%) — monitor sodium and supplement if needed; can be confused with SIADH
Nausea/vomiting management critical for adherence: ondansetron + dexamethasone + lorazepam prophylaxis recommended; appetite stimulants (olanzapine low-dose) used in practice
Thrombocytopenia may require dose interruption or reduction; platelet transfusions if <50 × 10⁹/L with bleeding; eltrombopag or romiplostim not routinely used alongside selinexor

Contraindications

Severe hepatic impairment
Known hypersensitivity
Pregnancy

Side effects

Nausea/vomiting (most common, often severe — antiemetic prophylaxis essential)
Thrombocytopenia
Fatigue
Hyponatraemia
Anorexia/weight loss
Neutropenia
Diarrhoea

Interactions

Strong CYP2C8 inhibitors — may increase selinexor exposure
CNS depressants — additive; selinexor can cause confusion/cognitive effects
Warfarin — monitor INR closely; potential pharmacodynamic interaction

Monitoring

FBC (weekly ×3, then monthly)
Sodium levels (monthly)
Weight and nutritional status (monthly)
LFTs
Nausea/vomiting score (each visit)
Neurological status

Reference: BNFc; BNF 90; BOSTON trial (Grosicki et al. NEJM 2020); NICE TA680; MHRA SPC Nexpovio; STORM trial (Chari et al. NEJM 2019 — penta-refractory). Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways