Multiple Myeloma Flashcards
What is the most common type of multiple myeloma?
IgG
What classifies MGUS?
- M protein <3 g/dL
- Bone marrow plasma cells <10%
- No end organ damage
What classifies smoldering MM?
- M protein >3 g/dL
- Bence-Jones protein >500 mg/24h
- Bone marrow plasma cells 10-59%
- No end organ damage
What classifies multiple myeloma?
- M protein >3 g/dL
- Bone marrow plasma cells >10%
- Biopsy
- End organ damage
What criteria DIAGNOSES multiple myeloma?
SLiMCRAB
- >Sixty% bone marrow plasma cells
- Light chains >100
- MRI >1 focal lesion >5mm
- Calcium >1 mg/dL above ULN or >11
- Renal clearance <40 mL/min
- Anemia hemoglobin >2 below LLN or <10
- Bone >1 osteolytic lesion on imaging
What are consequences of bone disease?
- Lytic lesions and fractures
- Anemia
- Hypercalcemia
What causes renal impairment in multiple myeloma?
- Hypercalcemia
- Myeloma cast nephropathy (light chain precipitation)
- Concomitant nephrotoxic agents
What is the preferred bone agent for hypercalcemia of malignancy?
Full-dose zoledronic acid (not renally adjusted)
Which prophylactic agents should be started in all new MM patients?
Levofloxacin and acyclovir
What is the gold-standard treatment for MM?
Triplet therapy
- Revlimid (lenalidomide)
- Velcade (bortezomib)
- Dexamethasone
(Autologous/Allogenic) transplant is preferred consolidation after chemotherapy
Autologous
When is Daratumumab-RVd considerable (studied)?
Newly diagnosed transplant-eligible patients
What are side effects of daratumumab?
- Infusion reactions
- Herpes reactivation
- HepB reactivation
- Lab interference
What do we premedicate with before giving daratumumab?
- APAP
- Dexamethasone
- Antihistamine
- Montelukast
What post-treatment do we give for daratumumab?
Methylprednisolone 20mg x2 days after each dose for the first cycle only
Which formulation of bortezomib is preferred due to dose-limiting side effects?
SQ
What are side effects of bortezomib?
- Herpes reactivation
- Thrombocytopenia
- Peripheral neuropathy
What are drugs in the same class as bortezomib?
Carfilzomib (IV, pulmo/cardiotoxic)
Ixazomib (oral, GI toxic)
What are side effects lenalidomide?
- Birth defects
- Hematologic toxicity
- Thrombotic events
- Somnolence
- Increased risk of secondary malignancy
- Rash, skin toxicity
- Diarrhea
- Peripheral neuropathy
What birth control is required to take lenalidomide?
- Highly effective birth control (IUD, hormonal, etc…)
- Additional effective birth control (male condom, cap)
What do we start all patients taking IMiDs on for anticoagulation?
Enoxaparin 40 mg QD
Move to aspirin 81 mg QD after a partial response (M protein <50%) is achieved and no other risk factors
What are side effects of dexamethasone?
- Insomnia
- Mood changes
- Increased appetite
- GI upset/reflux
- Hyperglycemia
- Edema
- Weight gain
- HTN
What OTC considerations should be taken for patients on MM regimens?
- Imodium for diarrhea
- Avoid NSAIDs due to nephrotoxicity
When can we use BiTEs?
After 4 failed lines of therapy
What BiTE drugs do we have available?
- Talquetamab
- Teclistamab
- Elranatamab
What are side effects of talquetamab (GPRC5D)?
- CRS
- Neurotoxicity
- Cytopenias
- Rashes
- Skin and nail toxicity
- Taste change
- Weight loss
What are side effects of teclistamab/elranatamab (BCMAs)
- CRS
- ICANS
- Cytopenias
What is required for patients to take BiTEs therapy?
- Step-up dosing, sometimes hospital administration
- REMS program
- BiTE card for reactions to look out for
What do we do for CRS treatment?
Supportive care, treat like a transplant
What do we do for immune effector cell-associated neurotoxicity (ICANS)?
Grade with ICE score (high is better)
- Supportive care
- Steroids
- Anti-seizure medications
