Treatment Guideline Chart

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.


Multiple%20myeloma Treatment

Supportive Therapy

  • 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


  • 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


  • 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


  • 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)
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