multiple%20myeloma
MULTIPLE MYELOMA

Multiple myeloma is a bone marrow disease characterized by the presence of malignant plasma cells, & abnormal serum &/or urine immunoglobulin secondary to clonal plasma cell expansion.

It accounts for 1-2% of all cancers worldwide & mostly affects patients at ages 65-74 years old.

Patient usually presents with bone pain & nonspecific symptoms, or due to abnormalities in laboratory exams.

 

Supportive Therapy

  • Should be considered for all patients, regardless if eligible for SCT or not

Bone Disease

  • Indications for initiation of treatment for bone disease include:
    • Radiographic evidence of lytic disease (eg lytic bone destruction, spinal compression fracture secondary to osteopenia)
    • Presence of osteopenia without evidence of lytic bone disease
    • Adjunct to pain control in patients w/ osteolytic disease suffering from pain & those receiving treatment for fractures or impending fractures
    • Presence of osteopenia or osteoporosis in patients w/ multiple myeloma even if without evidence of lytic bone disease on plain radiograph
    • Presence of MGUS w/ confirmed osteopenia 
  • Pamidronate & Zoledronic acid are recommended for patients w/ bone disease secondary to multiple myeloma (eg osteopenia, osteolytic lesions)
  • Denosumab may be considered as an alternative to bisphosphonates for the prevention of bone disease in multiple myeloma
  • Dental clearance should be obtained prior to initiation of bisphosphonate therapy
  • Monitoring of renal function & symptoms of osteonecrosis of the jaw are recommended during bisphosphonate therapy
  • Patients w/ intolerable pain due to pathologic fracture or cord compression may opt to undergo low-dose radiation therapy (10-30 Gy in 2.0-3.0 Gy fractions)
  • Surgical management via kyphoplasty or vertebroplasty may also be considered for symptomatic vertebral compression fractures

Anemia

  • Decreased hemoglobin levels of <10 g/dL may be treated w/ recombinant human erythropoietin & Darbepoietin alfa
  • Red blood cell transfusion may also be considered in patients w/ abrupt need for increased Hgb levels
  • Patients who develop severe granulocytopenia after chemotherapy may be considered for granulocyte-stimulating factor (G-CSF) therapy

Hypercalcemia

  • Adequate hydration, bisphosphonates (eg Zoledronic acid, Pamidronate, Ibandronate), Denosumab, corticosteroids, & Calcitonin may be given to patients w/ increased bone resorption secondary to bone disease in myeloma

Renal Impairment

  • Bortezomib-based regimens (eg Bortezomib plus Dexamethasone w/ or without Thalidomide, Doxorubicin, or Cyclophosphamide) is recommended for patients w/ renal failure

Venous Thromboembolism (VTE)

  • Hyperviscosity & hypercoagulability due to multiple myeloma lead to increased risk for thrombosis formation
  • Multiple myeloma patients are at increased risk for thrombotic events especially during chemotherapy w/ Doxorubicin & immunomodulatory drugs (IMiDs) (eg Lenalidomide, Pomalidomide, Thalidomide) w/ Dexamethasone
  • Aspirin is recommended for patients w/ low risk for VTE receiving IMiD-based therapy
  • Low molecular weight heparin or Warfarin is recommended for patients at increased risk for thrombosis

Infection/Reactivation

  • Prevention of infectious complications by administration of IVIg, anti-infective prophylaxis, & vaccinations are recommended
    • Vaccination for influenza & S pneumoniae is recommended
    • IV immunoglobulin replacement therapy may be considered for patients w/ recurrent, severe infection despite prophylactic antibiotic therapy
    • Prophylaxis against Pneumocystis carinii pneumonia (PCP) & fungal infection should be considered in patients being given high-dose regimens
    • Patients being treated w/ protease inhibitors especially Bortezomib, Carfilzomib, Ixazomib, & Daratumumab or undergoing ASCT or allo-SCT should receive prophylaxis for herpes zoster (eg Acyclovir, Valaciclovir)
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