Lec 2: Multiple Myeloma Flashcards
MM is 68 year old male with PMH significant for controlled type 2 diabetes. Patient presents to the emergency department with a 3 week history of increasing lower back pain (rated 7 out of 10, had previously been 4 out of 10), confusion, and fatigue. He reports difficulty with activities of daily living which he
was previously able to complete without issue.
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Pertinent labs – Hgb 8.1, calcium 11.5 mg/dL, SCr 1.0, albumin 3.1.
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The patient is found to have several osteolytic lesions and a spinal compression fracture on CT scan. Bone marrow biopsy shows 70% plasma cells. Patient is diagnosed with multiple myeloma.
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Based on the patient case, which complications of myeloma is this patient presenting to the ED with?
A. Pathologic fracture
B. Hypercalcemia
C. Renal insufficiency
D. A and B
E. All of the above
D. !
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NOTE: patient has “spinal compression fracture” and his calcium is high! - must correct it b/c albumin is low!
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Hgb is lower and
Scr is normal (no renal issues yet)
MYELOMA INCIDENCE
14 occurring cancer so it’s not common but mortality is high due to no cure
WHAT IS MULTIPLE MYELOMA?
- Blood cancer that affects plasma cells in the bone marrow
- Malignant plasma cells produce an antibody known as the M protein
—- Can lead to: Bone destruction (causing fractures), Kidney damage (these plasma cells get stuck in glomerulus), Impaired immune function (cuz you’re not producing normal immune cell) - Not curable but highly manageable
Multiple Myeloma: RISK FACTORS
-Increasing age (most frequently diagnoised at age of 65-74; median age 69)
-Males
-Family history of multiple myeloma
-Personal history of Monoclonal Gammopathy of Unknown Significance (MGUS)
-Environmental exposures (eg. 9/11 responders)
MM: CLINICAL PRESENTATION
-Bone pain (hallmark presentation)
-Nausea
-Hypercalcemia
-Constipation
-Loss of appetite
-Mental fog/confusion
-Frequent infections
-Weight loss
-Weakness/numbness in legs
-Excessive thirst
MM: Clinical Presentation: HYPERCALCEMIA (and the importance of albumin)
-Corrected calcium equation
Corrected Ca = serum Ca + 0.8*(4 - serum albumin)
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When looking at calcium you need to check albumin level and adjust the Ca if the albumin is low. (lower than 4)
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NOTE: cut off is at 12! is they’re corrected calcium is over 12 we want to do pharmtx beyond hydration! (we need to use bisphosphonates, calcitonin)
CRAB CRITERIA: a mnemonic aid covering four features that are associated with end-organ damage linked to myeloma progression
-Calcium elevation
-Renal impairment
-Anemia
-Bone lesions
MYELOMA CLASSIFICATION (part 1): Smoldering Myeloma (asymptomatic)
For asymp myeloma? we’re mainly just gonna observe the patient to make sure they do not progress
MYELOMA CLASSIFICATION (part 2): Symptomatic Multiple Myeloma
*Myeloma defining events mainly focuses on CRAB criteria
POSSIBLE MYELOMA RELATED
COMPLICATIONS
1.) Infections: can be due to disease burden or treatment (the WBC that are produce are not working as well!)
2.) Coagulation/thrombosis: myeloma and certain treatments increase risk of thrombosis
3.) Pathologic fractures
TREATMENT CONSIDERATIONS FOR MM
-Transplant candidate? (this is the best way to prolong life! We want to try to get patient to be transplant candidate!)
-Comorbidities
-Performance status
-NCCN Guidelines
THERAPY DRUG CLASSES FOR FIRST LINE THERAPY FOR MM
1.) Proteasome inhibitors
2.) Immunomodulators (Imids)
3.) Anti-CD38 antibodies
4.) Steroid (dexamethasone)
PROTEASOME INHIBITORS : MOA, Route, Toxicities
PROTEASOME INHIBITORS: more info on route and unique tox
IMMUNOMODULATORS: MOA, Route
ANTI-CD38 MONOCLONAL ANTIBODY: MOA, Route, Toxicity
DEXAMETHASONE: MOA, Route, Doses, Common toxicities
NCCN INITIAL THERAPY RECOMMENDATIONS: FIRST LINE THERAPY – TRANSPLANT CANDIDATES
NCCN INITIAL THERAPY RECOMMENDATIONS: FIRST LINE THERAPY – NONTRANSPLANT CANDIDATES . . not as many options as transplant candidate
MYELOMA SALAD BAR
