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  • imageMultiple myeloma (MM) is a cancer that develops in plasma cells, leading to excessive production of a monoclonal immunoglobulin.

  • imageMost patients have skeletal involvement at the time of diagnosis with associated bone pain and fractures. Anemia, hypercalcemia, and renal failure may also be present.

  • imageInitial therapy for patients with newly diagnosed MM should be personalized based on cytogenetics and tools such as the Mayo Stratification for Myeloma and Risk-Adapted Therapy (mSMART).

  • image Primary treatment selection is based on the patient’s eligibility for an autologous hematopoietic stem cell transplantation. Immunomodulatory agents and proteasome inhibitors are used over traditional chemotherapy because of higher response rates and survival. The increased response rate is at the expense of significant grade 3 and 4 toxicity, which may include myelosuppression, venous thromboembolism (VTE), and neuropathy depending on the regimen used.

  • imageThalidomide, lenalidomide, and pomalidomide are immunomodulatory agents with antiangiogenic and anti-inflammatory activity. Lenalidomide is widely utilized compared to thalidomide due to increased potency and less adverse effects. Pomalidomide is currently only used in relapsed/refractory MM.

  • imageThe proteasome inhibitors, bortezomib, carfilzomib, and ixazomib, are highly active in the treatment of MM, particularly in those with high-risk cytogenetics.

  • imageAutologous hematopoietic stem cell transplantation (HSCT) is used after induction in patients with reasonably good performance status to maximize complete remissions and prolong survival. Combining autologous HSCT with allogeneic HSCT is investigational and should be performed within a clinical trial.

  • imageMaintenance therapies may be used in both transplant-eligible and ineligible patients. Current regimens usually include lenalidomide or bortezomib with the intent of increasing progression-free survival.

  • imageBisphosphonates are used to treat bone disease associated with MM, which results in decreased pain and skeletal-related events and improved quality of life.

  • imageSalvage therapy for patients with relapsed or refractory MM can include any of the prior therapies and depends on the patient’s performance status, risk category, and prior treatments used for induction.


Patient Care Process for Multiple Myeloma



  • Patient characteristics (eg, age at diagnosis)

  • Patient medical history (personal and family)

  • Patient comorbidities

  • Patient organ function

  • Current medications including OTC agents

  • Prior treatment history for myeloma, if any

  • Objective data

    • Labs including CBC, comprehensive metabolic panel, β2-microglobulin

    • Results of bone scan


  • Indication for therapy

  • Impact of comorbidities on tolerance of therapy (eg, diabetes)

  • Health literacy and adherence

  • Emotional status (eg, presence of anxiety, depression)

  • Ability/willingness to pay for antimyeloma treatment options (PO vs IV therapy)


  • Drug therapy regimen (upfront therapy versus transplant versus relapse therapy)

  • Supportive care regimen (treatment of anemia, renal dysfunction, use of bone modifying agents)

  • Monitoring parameters including efficacy and safety; frequency and timing of follow-up

  • Patient education (eg, goal of therapy, schedule of treatments, adherence, self-monitoring)


  • Provide patient education

  • Assess steps needed for insurance approval for oral/at home agents

  • Ensure follow-up appointments are scheduled for active and supportive therapy

Follow-up: Monitor and Evaluate

  • Response (minimum residual disease, M-protein)

  • Safety (skeletal-related events, ...

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