Treatment Options for Multiple Myeloma
The treatment options for multiple myeloma may include:
1. Initial Therapy for Multiple Myeloma
The initial chemotherapy used to treat multiple myeloma depends on whether you're considered a candidate for stem cell transplantation and your individual risk profile. Factors such as the risk of your disease progressing, your age and your general health play a part in determining whether stem cell transplantation may be right for you.
- If you're considered a candidate for stem cell transplantation, your initial therapy will likely exclude melphalan because this drug can have a toxic effect on stem cells, making it impossible to collect enough of them. Your first treatment will typically be lenalidomide or bortezomib combined with low-dose dexamethasone.
Your stem cells will likely be collected after you've undergone three to four months of treatment with these initial agents. You may undergo the stem cell transplant soon after your cells are collected or the transplant may be delayed until after a relapse, if it occurs. Your age and your personal preference are important factors in determining when to do the transplant.
- If you're not considered a candidate for stem cell transplantation, your initial therapy is likely to be a combination of melphalan, prednisone and thalidomide — often called MPT — or melphalan, prednisone and bortezomib (Velcade) — often called MPV. If the side effects are intolerable, melphalan plus prednisone (MP) or lenalidomide plus low-dose dexamethasone are additional options. This type of therapy is typically given for about 12 to 18 months.
2. Standard Treatments for Multiple Myeloma
Though there's no cure for multiple myeloma, with good treatment results you can usually return to near-normal activity. You may wish to consider approved clinical trials as an option. Standard treatment options include:
Bortezomib (Velcade). Bortezomib was the first approved drug in a new class of medications called proteasome inhibitors. It is administered intravenously. It causes cancer cells to die by blocking the action of proteasomes. It is approved for people with newly diagnosed and previously treated myeloma.
Chemotherapy. Chemotherapy involves using medicines — taken orally as a pill or given through an intravenous (IV) injection — to kill myeloma cells. Chemotherapy is often given in cycles over a period of months, followed by a rest period. Often chemotherapy is discontinued during what is called a plateau phase or remission, during which your M protein level remains stable. You may need chemotherapy again if your M protein level begins to rise. Common chemotherapy drugs used to treat myeloma are melphalan (Alkeran), cyclophosphamide (Cytoxan), vincristine, doxorubicin (Adriamycin) and liposomal doxorubicin (Doxil).
Corticosteroids. Corticosteroids, such as prednisone and dexamethasone, have been used for decades to treat multiple myeloma. They are typically given in pill form.
Lenalidomide (Revlimid). Lenalidomide is chemically similar to thalidomide, but because it appears to be more potent and cause fewer side effects, it is currently used more often than thalidomide. Lenalidomide is given orally. It is approved for people with previously treated myeloma, but is also often used in people with newly diagnosed disease.
Radiation therapy. This treatment uses high-energy penetrating waves to damage myeloma cells and stop their growth. Radiation therapy may be used to quickly shrink myeloma cells in a specific area — for instance, when a collection of abnormal plasma cells form a tumor (plasmacytoma) that's causing pain or destroying a bone.
Stem cell transplantation. This treatment involves using high-dose chemotherapy — usually high doses of melphalan — along with transfusion of previously collected immature blood cells (stem cells) to replace diseased or damaged marrow. The stem cells can come from you or from a donor, and they may be from either blood or bone marrow.
Thalidomide (Thalomid). Thalidomide, a drug originally used as a sedative and to treat morning sickness during pregnancy in the 1950s, was removed from the market after it was found to cause severe birth defects. However, the drug received approval from the Food and Drug Administration (FDA) again in 1998, first as a treatment for skin lesions caused by leprosy. Today thalidomide is FDA approved for the treatment of newly diagnosed multiple myeloma. This drug is given orally.
3. Treatments for Relapsed or Treatment-resistant Multiple Myeloma
Most people who are treated for multiple myeloma eventually experience a relapse of the disease. And in some cases, none of the currently available, first line therapies slow the cancer cells from multiplying. If you experience a relapse of multiple myeloma, your doctor may recommend repeating another course of the treatment that initially helped you. Another option is trying one or more of the other treatments typically used as first line therapy, either alone or in combination. Research on a number of new treatment options is ongoing, and these drugs offer important options for those with multiple myeloma. Talk to your doctor about what clinical trials may be available to you.
Treatment of Multiple Myeloma Complications
Because multiple myeloma can cause a number of complications, you may also need treatment for those specific conditions. For example:
Anemia. Anemia (low red blood cell count) that is causing symptoms may require blood transfusions or treatment with erythropoietin (EPO), a substance that stimulates the production of red blood cells. Erythropoietin is usually given by injection one to three times per week. This treatment effectively increases levels of hemoglobin (the protein in red blood cells that helps carry oxygen to the tissues), improves symptoms, and reduces the need for blood transfusion.
Bone pain and fractures. Physical activity, with careful avoidance of injury, can promote bone strength in individuals with multiple myeloma. The bone pain associated with multiple myeloma can be controlled with chemotherapy, analgesics (pain relieving drugs), radiation, and bone strengthening drugs such as zoledronic acid (Zometa) or pamidronate (Aredia) (commonly referred to as bisphosphonates) that can also reduce the likelihood of fractures.
In individuals who have early signs of bone erosion, bisphosphonates reduce the risk of fractures and reduce bone pain. Therefore, bisphosphonates are recommended for all individuals who have early signs of bone erosions on x-rays. Bisphosphonates are usually given by intravenous infusion every four weeks; this treatment is continued for approximately two years. These medications may affect kidney function, which should be monitored on a regular basis to avoid this complication. Dental procedures, such as root canal or extraction of teeth, may be associated with infection or destruction of the jaw (osteonecrosis) in patients treated with intravenous bisphosphonates. Accordingly, patients should avoid such procedures, if possible, while taking these agents; any needed dental procedures should be performed before these agents are started.
High blood calcium levels. High blood calcium levels develop as bone is lost. Individuals with MM should remain as active as possible because physical activity helps counter bone loss. The treatment of high blood calcium levels usually includes the use of intravenous fluids and prednisone. If this treatment is not effective, treatment with drugs that act against bone loss, such as zoledronic acid (Zometa) or pamidronate (Aredia), a class of drugs called bisphosphonates, may be recommended.
Impaired kidney function. Kidney function becomes impaired in about one half of individuals with multiple myeloma. The treatment of impaired kidney function is aimed at the specific underlying cause. Treatment usually includes intravenous fluids; it may also include dialysis (a type of blood filtration used for kidney failure), prednisone (a steroid that can indirectly lower blood calcium levels), and allopurinol, a drug that can lower blood levels of uric acid, a waste product from the increased turnover of the malignant plasma cells, which can damage the kidneys.
Patients are advised to stay well-hydrated and should drink enough fluid to produce three liters of urine daily if they have Bence Jones proteinuria (increased light chains in the urine). They should also avoid using any nonsteroidal anti-inflammatory drugs (NSAIDs, such as Advil, Motrin, Aleve) because these drugs might worsen kidney function. If impaired kidney function has progressed to kidney failure, the treatment options include hemodialysis or peritoneal dialysis. Advanced degrees of kidney failure are usually not reversible even if the multiple myeloma later responds to treatment.
Infection. Bacterial infections, often indicated by the presence of fever, require prompt treatment with antibiotics. Daily use of the antibiotic trimethoprim-sulfamethoxazole (Bactrim) can help prevent infections. Individuals who get frequent infections may be advised to take penicillin daily or rarely to have periodic intravenous infusions of gamma globulin. All individuals with multiple myeloma should receive the pneumococcal vaccine (which reduces the likelihood of pneumonia) and the influenza vaccine (which reduces the likelihood of flu).
Spinal cord compression. Spinal cord compression is a medical emergency that requires prompt treatment to prevent irreversible damage, such as paralysis. Initial treatment may consist of radiation and dexamethasone (a steroid) to reduce swelling around the spinal cord; if these measures are not effective, surgery is needed to relieve pressure on the spinal cord. Patients should call their doctor immediately if they have severe back pain; weakness, numbness, or tingling in the legs; or new problems with control over their