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Myeloma Round Table

Myeloma Round Table . Beth Faiman MSN, APRN-BC, AOCN Nurse Practitioner, Cleveland Clinic Pre-Doctoral Fellow, Case Western Reserve . Hematologic events: Neutropenia and Thrombocytopenia . Neutropenia Functional neutrophils are critical to the immune system

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Myeloma Round Table

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  1. Myeloma Round Table Beth Faiman MSN, APRN-BC, AOCN Nurse Practitioner, Cleveland Clinic Pre-Doctoral Fellow, Case Western Reserve

  2. Hematologic events: Neutropenia and Thrombocytopenia • Neutropenia • Functional neutrophils are critical to the immune system • Neutropenia can occur from treatment or the disease itself • Educate signs and symptoms of infection • Risk is primarily during times of low WBC or treatment with agents that lower immune function Miceli et al, 2008.

  3. Hematologic events: Neutropenia and Thrombocytopenia • Prophylactic antibiotic usage for neutropenia is controversial • Generally not done except during high-dose therapy (transplant setting) or if planned prolonged neutropenia in high-risk patients • Treatment • Colony-stimulating factors increase WBC • Sargramostim • Filgrastim • Peg-filgrastim • Treat the myeloma itself if disease related Miceli et al, 2008.

  4. Thrombocytopenia • Low blood platelets • May be a result of treatment of disease itself (marrow crowded out by atypical plasma cells • Signs: • Bleeding • Purpura • Petechiae • Diagnosis • Low Platelet count (normal 150-400) • Treatment • Watchful waiting • Treat disease • Platelet transfusion • Hold anti-myeloma therapy if indicated • Bortezomib, lenalidomide, etc. UTI = urinary tract infection; IVIG = intravenous immunoglobulin; PCP = pneumocystis pneumonia. Paradisi et al, 2001; Kollef, 2008; Gooskens et al, 2009; Ferguson et al, 2009; Pneumovax® prescribing information, 2009; Zostavax® prescribing information, 2009.

  5. Hypercalcemia and Bone Loss • Hypercalcemia in 15% of patients • Increased calciumlevels, dehydration can precipitate renal failure • Treat with pamidronate, hydration, treat the disease • Pathobiology: Malignant cells produce osteoclast- activating factors that destroy bone cells • Osteoclast stimulation leads to extensive osteolysis, severe bone pain, and pathologic fractures • Spinal cord compression • Plasmacytoma with significant bone destruction • Most visible aspect of myeloma • 80% of patients develop bone disease Roodman, 2008.

  6. Symptoms Altered LOC, constipation, coma Diagnosis: Confirm by measuring CSC mg/dL (4.0 – serum ALB g/dL) Serum calcium mg/dL + 0.8 Example Calcium = 11.0 mg/dL ALB = 3.0 mg/dL 4.0 - 3.0 = 1.0 Multiply (1.0) by 0.8, and add to the calcium of 11.0 CSC = 11.8 mg/dL Hypercalcemia of Malignancy LOC = level of consciousness; CSC = corrected serum calcium. Payne, 2004.

  7. Renal Dysfunction • Bence-Jones proteinuria: Incidence ~ 70% • Light chain Igs can precipitate and damage renal cells • Free light chains filtered in the nephron’s glomerulus, then absorbed and metabolized by proximal tubular cells • Heavy and light chains can cause renal tubular damage • sFLC assay more reliable than urine • ATN secondary to NSAIDS, dehydration, nephrotoxic agents (CT dyes) • Supportive therapy • Hydration, correct underlying cause with treatment • Avoid IV contrast and nephrotoxic agents (IV dyes, NSAIDS) • Plasmapheresis, dialysis ATN = acute tubular necrosis; NSAIDS = non-steroidal anti-anflammatory drugs. Rajkumar et al, 2001; Dimopoulos et al, 2008; Botchler et al, 2008; Wong et al, 2007.

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