Multiple myeloma

Multiple myeloma - Chronic
Rahul Soman, M. Pharm

 

Definition  

A clonal B lymphocyte malignancy

 

Medical History  

* Family history of Multiple myeloma

* Black or African American

* Aging

* Past medical history of Monoclonal gammopathy of uncertain significance

 

Findings  

* Asthenia

* Bleeding

* Bone pain

* Bone tenderness

* Fever

* Hyperviscosity syndrome

* Increased susceptibility to infections

* Pathological fracture

* Ataxia

* Confusion

* Depression - Chronic

* Headache

* Increased frequency of urination

* Increased thirst

* Nausea

* Paresthesia

* Plasmacytoma

* Retinal hemorrhage

* Visual disturbance

* Anemia - Chronic

* Carpal tunnel syndrome - Chronic

* Cryoglobulinemia

* Enlargement of tongue

* Fatigue

* Lethargy

* Pallor

* Purpuric disorder

* Weight loss

* Optic disc edema

 

Tests  

 

Multiple myeloma  

* Creatinine measurement, serum

* Serum protein electrophoresis

 

Suspected or known monoclonal proteinemia  

* Immunofixation electrophoresis, Urine: Immunofixation is useful for confirming the presence of a monoclonal protein and for identifying the specific type in monoclonal paraproteinemias .

 

Suspected or known plasma cell dyscrasia  

* Complete blood count with white cell differential, manual: Anemia is a common finding in plasma cell dyscrasias. Neutropenia and thrombocytopenia may be seen in advanced disease.

 

Suspected or known plasma cell dyscrasia  

* Bone marrow biopsy, needle or trocar: Bone marrow biopsy may be useful to confirm the diagnosis of and assess prognosis and treatment response in plasma cell dyscrasias .

 

Suspected plasma cell dyscrasia  

* Peripheral blood smear examination, light microscopy: The presence of red cell rouleaux formation should raise the suspicion of dysproteinemia.

 

Suspected and known monoclonal gammopathies  

* Immunofixation electrophoresis, Urine: In the appropriate clinical context, the presence of monoclonal globulin in the urine or serum suggests pathology .

 

Suspected and known multiple myeloma  

* Urine protein electrophoresis: Most patients with multiple myeloma have serum monoclonal bands with or without urinary monoclonal bands. Twenty percent of patients will have urinary monoclonal proteins only .

 

Suspected multiple myeloma  

* Erythrocyte sedimentation rate measurement: An elevated erythrocyte sedimentation rate may raise the suspicion of, but is not diagnostic for multiple myeloma. More specific studies are required .

 

Suspected or known monoclonal paraproteinemia  

* Immunofixation electrophoresis, Serum: Immunofixation electrophoresis identifies the specific monoclonal protein that is elevated in a plasma cell dyscrasia.

 

Differential Diagnosis  

* Monoclonal gammopathy of uncertain significance

* Multiple myeloma - Chronic

* Waldenström macroglobulinemia

* Plasmacytoma

* Non-secretory myeloma

* Smoldering myeloma

* Indolent multiple myeloma

* Plasma cell leukemia

* Heavy chain disease

* AL amyloidosis

* Osteosclerotic myeloma

* Low grade B-cell lymphoma

 

Treatment  

 

Drug Therapy  

 

Multiple myeloma  

 

MELPHALAN - PREDNISONE  

Adults: Melphalan 8-10 mg orally on days 1-7 AND prednisone 60 mg per day orally on days 1-7, regimen repeated every 6 weeks

 

VINCRISTINE SULFATE - CARMUSTINE - MELPHALAN - CYCLOPHOSPHAMIDE - PREDNISONE  

Adults: Vincristine 0.03 mg/kg (maximum 2 mg) IV on day 1 AND carmustine 0.5 mg/kg IV on day 1 AND melphalan 0.25 mg/kg orally on days 1-7 AND cyclophosphamide 10 mg/kg IV on day 1 AND prednisone 1 mg/kg orally on days 1-7; regimen repeated every 5 weeks

 

DEXAMETHASONE  

Adults: 40 mg orally on days 1-4, 9-12, and 17-20; regimen repeated every 4-5 weeks

 

VINCRISTINE SULFATE - DOXORUBICIN HYDROCHLORIDE - DEXAMETHASONE  

Adults: Vincristine 0.4 mg per day IV continuous infusion on days 1-4 AND doxorubicin 9 mg/m2 IV continuous infusion on days 1-4 AND dexamethasone 40 mg orally on days 1-4, 9-12, and 17-20; regimen repeated every 4 weeks

 

THALIDOMIDE

Adults: 200-400 mg orally on days 1-28; regimen repeated every 4 weeks

 

THALIDOMIDE - DEXAMETHASONE  

Adults: Thalidomide 200 mg orally on days 1-28 AND dexamethasone 40 mg orally on days 1-4, 9-12, and 17-20; regimen repeated every 4 weeks

 

MELPHALAN - PREDNISONE - THALIDOMIDE

Adults: Melphalan 4 mg/m2 orally on days 1-7 AND prednisone 40 mg/m2 on days 1-7 AND thalidomide 100 mg orally on days 1-28; regimen repeated every 4 weeks

 

CYCLOPHOSPHAMIDE - THALIDOMIDE - DEXAMETHASONE  

Adults: Cyclophosphamide 50 mg orally on days 1-21 AND thalidomide 200-800 mg orally on days 1-21 AND dexamethasone 40 mg orally on days 1-4; repeat regimen every 3 weeks

 

BORTEZOMIB

Adults: 1.3 mg/m2 on days 1, 4, 8, and 11 followed by a 10-day resting period every 21 days

 

Prevention of influenza in patients with multiple myeloma  

 

INFLUENZA VIRUS VACCINE (SUBVIRION)  

 

Prevention of streptococcal pneumonia in patients with multiple myeloma  

 

PNEUMOCOCCAL VACCINE POLYVALENT  

Adults: 0.5 ml IM or subQ every 5 years

 

Procedural Therapy  

 

Impending spinal cord compression, impending pathologic fracture, or palliative treatment of uncontrolled pain in patients with multiple myeloma  

* Radiation therapy