New guidelines on managing the complications of multiple myeloma and its treatment recommend whole-body, low-dose computed tomography over conventional radiography because of its superior sensitivity for detecting osteolytic lesions. The guidelines, drafted by the European Myeloma Network, also provide an imaging algorithm to address various clinical scenarios.
This is just one of the recommendations from the interdisciplinary panel that reviewed published randomized trials, guidelines, meta-analyses, systematic reviews, observational studies, and case reports on the topic. They graded their recommendations according to the strength of the evidence and, when evidence was insufficient, expert consensus.
“Multiple myeloma … is characterized by bone destruction, anemia, renal and immunological impairment. These complications may lead to severe impairment of the quality of life of myeloma patients and may deteriorate their life expectancy,” note the authors, who were led by Dr. Evangelos Terpos of the department of clinical therapeutics, National and Kapodistrian University of Athens (Haematologica. 2015;100:1254-66).
The panel endorsed addition of zoledronic acid (Zometa) or pamidronate (Aredia) to specific antimyeloma therapy for patients with adequate renal function who have bone disease at diagnosis. Although evidence is weaker, they note that symptomatic patients who do not have lytic lesions on conventional radiography can be treated with zoledronic acid; however, its use in patients with no bone involvement on computed tomography or magnetic resonance imaging has uncertain benefit. Additionally, they do not recommend use of bisphosphonates in asymptomatic patients.
The panel recommends that zoledronic acid be given continuously, although they add that benefit of continuous use is not clear in patients who achieve at least a very good partial response.
Treatment can be initiated with erythropoiesis-stimulating agents such as epoetin alfa (various brand names) and darbepoetin (Aranesp) in patients who have persistent symptomatic anemia (defined as a hemoglobin level of less than 10 g/dL) without any other apparent cause. However, these agents should be stopped after 6 to 8 weeks if hemoglobin response has not been adequate.
The panel notes that bortezomib(Velcade)-based regimens are the standard of care for patients with multiple myeloma who have renal impairment. Lenalidomide is an option, albeit with weaker evidence, in cases of mild to moderate renal impairment.
In patients who experience treatment-induced peripheral neuropathy, therapy should be modified by either altering the schedule or route of administration (as appropriate) or reducing the dose, according to the guidelines.
Patients with multiple myeloma (and their contacts) should be vaccinated against influenza, the panel recommends; vaccination against Streptococcus pneumonia and Haemophilus influenzae is “appropriate,” although efficacy is not guaranteed as patients are immunologically compromised.
The panel endorsed acyclovir (Zovirax) or valacyclovir (Valtrex) for herpes zoster virus prophylaxis in patients receiving proteasome inhibitors or undergoing autologous or allogeneic transplantation, mainly directed to patients who are seropositive.
Finally, clinicians should assess risk of venous thromboembolism in patients who are due to start immunomodulatory drug therapy and should use appropriate risk-based antiplatelet or anticoagulation therapy throughout treatment, according to the guidelines.
Dr. Terpos reported having no relevant disclosures.