Multiple%20myeloma Treatment

• Should be considered for all patients, regardless if eligible for HCT 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 with osteolytic disease suffering from pain and those receiving treatment for fractures or impending fractures
  • Presence of osteopenia or osteoporosis in patients with multiple myeloma even if without evidence of lytic bone disease on plain radiograph
  • Presence of MGUS with confirmed osteopenia 

• Bone-targeting treatment with bisphosphonates or Denosumab for up to 2 years is recommended for all symptomatic multiple myeloma patients receiving therapy 
• Pamidronate and Zoledronic acid are recommended for patients with 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
  • Preferred in patients with renal disease
• Dental clearance should be obtained prior to initiation of bisphosphonate therapy
• Monitoring of renal function and symptoms of osteonecrosis of the jaw are recommended during bisphosphonate therapy
• Patients with intolerable pain due to pathologic fracture or cord compression may opt to undergo low-dose radiation therapy (8 Gy x 1 fraction or 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 Hgb levels of <10 g/dL may be treated with recombinant human erythropoietin and Darbepoietin alfa
• Red blood cell transfusion may also be considered in patients with 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, and/or Calcitonin may be given to patients with increased bone resorption secondary to bone disease in myeloma

Renal Impairment

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

Venous Thromboembolism (VTE)

• Hyperviscosity and 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 with Doxorubicin and immunomodulatory drugs (IMiDs) (eg Lenalidomide, Pomalidomide, Thalidomide) with Dexamethasone
• Aspirin is recommended for patients with 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, and vaccinations are recommended
  • Vaccination for influenza and S pneumoniae is recommended
  • IV immunoglobulin replacement therapy may be considered for patients with recurrent, severe infection despite prophylactic antibiotic therapy
  • Prophylaxis against Pneumocystis jiroveci pneumonia (PJP) and fungal infection should be considered in patients being given high-dose regimens
  • Patients being treated with protease inhibitors especially Bortezomib, Carfilzomib, Isatuximab-irfc, Ixazomib, Daratumumab and Elotuzumab or undergoing AHCT or allo-HCT should receive prophylaxis for herpes zoster (eg Acyclovir, Valaciclovir)