1. Treatment Multiple Myeloma

2. Symptomatic/progressive myeloma: • Systemic therapy - to control progression of myeloma • Supportive care - to prevent serious from the complications of the disease *Initial standard treatment for newly diagnosed myeloma depends on whether or not the patient is a candidate for high dose chemotherapy with autologous stem cell transplant. Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

3. Transplant Candidates Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

4. Non – Transplant Candidates • Given 4-7 days every 4-6 weeks • Patients responding to therapy generally have a prompt and gratifying reduction in bone pain, hypercalcemia, and anemia, and fewer infections Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

5. High Dose Melphalan Therapy with hematopoietic stem cell support • can achieve high overall response rates and prolonged progression-free and overall survival • Two successive HDTs (tandem transplants) are more effective than single HDT in patients who don,t achieve a complete or very good partial response to the first transplant Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

6. Maintenance Therapy • No standard maintenance therapy to prolong time to progression IFN - has modest benefit but has significant side effects Oral prednisone - effective in a single trial Ongoing studies : thalidomide and lenalidomideto prolong progression-free survival post-transplant. Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

7. Relapse Lenalidomide and/or bortezomib • Used to treat relapsed myeloma • target not only the tumor cell but also the tumor cell–bone marrow interaction and the bone marrow milieu • In combination with dexamethasone • 60% partial responses and 10–15% complete responses Thalidomide • if not used as initial therapy, can achieve responses in refractory cases. High-dose melphalan and stem cell transplant • if not used earlier, also have activity in patients with refractory disease. Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.705

8. Major Causes of Death *Median overall survival : 5–6 years • progressive myeloma • renal failure • Sepsis • therapy-related acute leukemia or myelodysplasia Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.706

9. Supportive Care • directed at the anticipated complications Hypercalcemia • generally responds well to bisphosphonates (pamidronate 90 mg or zoledronate 4 mg once a month), glucocorticoid therapy, hydration, and natriuresis. • Calcitonin - adds to the inhibitory effects of glucocorticoids on bone resorption. Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.706

10. Supportive Care Iatrogenic worsening of renal function • prevented by maintaining a high fluid intake to prevent dehydration and to help excrete light chains and calcium • acute renal failure: plasmapheresis Urinary tract infections : watched for and treated early. Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.706

11. Supportive Care Hyperviscosity Syndromes: Plasmapheresis (treatment of choice) Recurrent serious infections: Prophylactic administration of IV globulin preparations Anemia • responds to erythropoietin along with hematinics (iron, folate, cobalamin) Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.706

12. Supportive Care Neurologic symptoms in the lower extremities, severe localized back pain, or problems with bowel and bladder control • emergency MRI and radiation therapy for palliation Bone lesions • respond to analgesics and chemotherapy Reference: 17th Ed. Harrison’s Principles of Internal Medicine p.706