Supportive Therapy for Multiple Myeloma

The treatment of multiple myeloma is focused on treating both symptoms and disease. The underlying disease is the increased number of abnormal plasma cells. A number of symptoms and medical problems result from the increased numbers of plasma cells, and from the abnormal M proteins they produce. Specific treatments are available for several of the complications that result from multiple myeloma.

Bone Damage/Lesions
In 70 percent of multiple myeloma cases, the bones develop multiple holes. That’s why the disease is called “multiple” myeloma. Doctors refer to the holes as “osteolytic lesions.” These lesions cause the bones to be fragile and subject to fractures. They are caused by the rapid growth of myeloma cells, which push aside normal bone-forming cells and prevent them from repairing general wear and tear of the bones. Under normal circumstances, cells called osteoclasts destroy dead and dying bone. Multiple myeloma causes increased numbers of these bone-destroying cells to be produced.

Multiple myeloma involving the bone can cause pain, fracture, and other significant problems. Managing this is an integral part of the overall treatment strategy. Your doctor’s first objective will be to prevent new bone disease from developing or existing bone lesions from progressing.

Bisphosphonate drugs can prevent the bone loss that results from bone lesions. They can reduce the risk of fractures and decrease pain. Bisphosphonate drugs that are FDA-approved for the treatment of cancer-related skeletal complications include Zometa^® (zoledronic acid) and Aredia^® (pamidronate). Both are given intravenously, or directly into a vein. A benefit of zoledronic acid is that it can be administered in 15 minutes, as opposed to pamidronate, which takes several hours. Most patients find the former more convenient.

Bisphosphonates can cause side effects. With ongoing use, a small fraction of patients may develop problems with kidney function or damage to the jawbone (osteonecrosis). It is a good idea to discuss these side effects with your doctor. You may wish to ask how your doctor plans to monitor you while you are taking bisphosphonates. Urine and/or blood tests can show whether or not your kidneys are being affected. Good mouth hygiene and regular dental visits can help in guarding against jaw damage, or catching it early if it develops.

Bone lesions also can cause pain. Low-dose radiation therapy may be used to target the myeloma cells that are collecting in certain bones and causing pain. Pain medication also may be given.

Other treatments may be given to control pain or restore function or mobility. These may include:

• Physical therapy
• Splinting of bones - to prevent or treat fractures
• Surgery - to repair fractures in the spine. Doctors can use two minimally invasive procedures to reinforce the vertebrae in the spine.
  

Hypercalcemia
Many multiple myeloma patients develop an increased level of calcium in the bloodstream known as hypercalcemia. Hypercalcemia results from the destruction of bone from bone destroying lesions. It may also result from the development of generalized osteoporosis, in which all the bones have lost calcium and have become soft and porous. In patients with multiple myeloma, hypercalcemia causes fatigue, lethargy, and other symptoms. Typically, hypercalcemia is treated with bisphosphonates and the drinking of ample fluids. Severe hypercalcemia is a medical emergency requiring immediate treatment.

Anemia
Anemia is a common complication of multiple myeloma. It occurs when your body does not have enough red blood cells and/or hemoglobin, the oxygen-carrying protein these cells produce. As the abnormal plasma cells, or myeloma cells, crowd the bone marrow, they can prevent it from making enough red blood cells. People with anemia may experience tiredness, fatigue, and shortness of breath.

To help with these symptoms, your doctor may prescribe Procrit^® (erythropoietin) or a related product called Aranesp^® (darbepoetin alfa). These are growth factors that help the bone marrow produce more red blood cells, which improves hemoglobin levels.

Infections
The depletion of normal white blood cells puts you at increased risk for infection. If you experience recurrent infections or you have a low white blood cell count, your doctor may prescribe a colony-stimulating factor. These stimulate the production of white blood cells. Examples include Neupogen^® (filgrastim), Neulasta^® (pegfilgrastim), and Leukine^® (sargramostim).

If you develop an infection, it may require treatment with antibiotics or intravenous immunoglobulin therapy. This therapy involves receiving a mixture of antibodies (infection-fighting proteins) made from donated human plasma. This can help boost your immune system and fight infection at a time when you do not have enough healthy white blood cells.

Possible signs of infection include high fever (above 100.5° F), chills or sweats, cough, sore throat, mouth sores, changes in your urine or stools, or just an overall sick feeling. Check with your doctor if you experience any of these symptoms.

Kidney Problems/Systemic Light Chain Amyloidosis
Myeloma cells also can produce proteins called “light chains” or “Bence Jones proteins” after the British physician who discovered them. These proteins may clog the kidney, damaging it, and ultimately causing it to fail. Hypercalcemia may make this worse because excess calcium in the blood causes fluid loss and dehydration.

Because Bence Jones proteins are eliminated through the urine, they may accumulate in the kidneys and cause kidney dysfunction. Therefore, it is important for you to drink enough fluids to help prevent kidney failure and to avoid using over-the-counter medications, such as NSAIDS (nonsteroidal anti-inflammatory drugs) that can worsen kidney function.

In addition to affecting the kidneys, these “light chain” proteins can affect the heart, liver, and spleen. In some cases, they can cause these organs to fail. Clinical trials are now under way to determine the best ways to treat this condition. Options include various combinations of steroid and chemotherapy drugs, as well as high-dose chemotherapy and stem cell transplant.

Waldenström’s Macroglobulinemia
This condition results when a certain protein produced by the myeloma cells, called immunoglobulin M (igM), builds up in the body. It can cause the blood to thicken and may damage the liver and spleen. Several chemotherapy options and biologic therapy can be used to treat macroglobulinemia.