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J:Breast Cancer > Multiple Myeloma > Flashcards

Multiple Myeloma Flashcards

1
Q

What are the risk factors for multiple myeloma?

A
  1. Genetics (MGUS, African, First Degree Relative)
  2. Radiation & Chemical Exposure
    –> Ionizing Radiation, Pesticides, Herbicides
    –> Aromatic Hydrocarbons & Petroleum Products
    —> Volatile Organic Compounds
  3. Suppressed Immune System
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2
Q

What is multiple myeloma?

A

The result of dysregulation produces excessive plasma cells and therefore antibodies known as monoclonal protein and M-protein.

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3
Q

Describe the progression of Plasma Cell Disorders

A

Slide 7

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4
Q

What is SLiM-CRAB?

A

Algorithm to indicate if you have end-organ damage?

Slide 8

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5
Q

Describe the pathophysiology of Bone Disease in Multiple Myeloma?

A

Myeloma Cells Infiltrate the Bone Marrow —> Increase production of inflammatorycytokines

+

Increased osteoclast activity (upregulated Rank-L)
Decreased Osteoprotegerin production

= Increased number of focal lesions inversely related to overall and event-free survival.

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6
Q

What are the consequences of bone disease in multiple myeloma?

A
  1. Lytic Lesions and Fractures (80%)
  2. Anemia
  3. Hypercalcemia
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6
Q

Describe the pathophysiology of Renal Impairment & Anemia:

A

Slide 11

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7
Q

What is involved in the initial work up for Multiple Myeloma?

A

Slide 12

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8
Q

What is the usual patient presentation in Multiple Myeloma?

A

Slide 13

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9
Q

Review the Staging for Multiple Myeloma

A

Slide 14

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10
Q

Describe the response scoring of Multiple Myeloma

A

Slide 15

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11
Q

Is Myeloma curable?

A

No, Patients will be on lifelong therapy.

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12
Q

What is the general sequence to treating multiple myeloma?

A

Induction —> Consolidation —> Maintenance —-> Relapse

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13
Q

What type of transplant is preferred after induction?

A

Autologous

Allogenic –> Can cure but are associated with high toxicity and mortality

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14
Q

What is the goal of therapy in regards to transplant?

A

To collect enough cells for 2 transplants within the first 4-6 cycles of therapy.
*Avoid stem cell toxins prior to collection.

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15
Q

What are the primary induction therapies for multiple myeloma?

A

Slide 20

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16
Q

What is the gold standard of therapy?

A

*Triplet Regimen VRd)

Velcade (Bortezomib)
+
Revlimid (Lenalidomide)
+
Dexamethasone

–> Some patients benefit from the addition of daratumumab.
——> Triplet therapy is still preferred for non-transplant candidates, but doublets can be reserved for older or frail patients.

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17
Q

What is Dara-VRd 28 day Regimen?

A

Daratumumab: 1800 mg SQ QW x 8 , then QOW x 8, QM

Bortezomib: 1.3 mg/m2 SQ on days 1,8,15

Lenalidomide: 25 mg PO QD 1-21

Dexamethasone: 40 mg QW

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18
Q

What is the mechanism of action of Daratumumab?

A

CD-38 mAB
–> Isatuximab is another drug in this class.

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19
Q

What are the formulations of Daratumumab? Which is preferred?

A

SQ (1800 Flat Dose) = Preferred

IV (16 mg/kg)

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20
Q

What is the preferred premedication for Daratumumab?

A
  1. Steroid (Dexa or Methylprednisolone)
  2. APAP
  3. Antihistamine
  4. Montelukast
21
Q

What medication should be given after Daratumumab to prevent reactions?

A

Methylpred 20 mg x 2 days after each dose for the first cycle only

22
Q

What are the side effects of Daratumumab?

A
  1. Infusion Reactions
  2. Herpes Zoster Reactivation
  3. Hepatitis B reactivation
  4. Lab Interference
23
Q

What is the mechanism of Bortezomib?

A

Proteasome Inhibitor
—> Inhibits the S20 subunit of proteasome causing apoptosis

24
Which formulation of bortezomib is preferred?
1. SQ (preferred) 2. IV
25
What are the side effects of Bortezomib?
1. Herpes Zoster Reactivation 2. Thrombocytopenia 3. Peripheral Neuropathy (Bortezomib > Ixzomib > Carfilzomib)
26
What is the mechanism of action of Lenalidomide?
--> Immunomodulatory Drug -----> Anti-angiogenic upregulation of pro-apoptotic factors factors, decreased anti-apoptotic factors, decreased production of cytokines, enhanced T-cell and NK-cell proliferation and activity.
27
What other drugs are in the same class as Lenalidomide?
Thalidomide, Pomalidomide
28
How is Lenalidomide administered?
By Mouth
29
What are the side effects of Lenalidomide?
1. Birth Defects 2. Hematologic Toxicity 3. Thrombotic Events 4. Somnolence 5. Increased Risk of Secondary Malignancy 6. Rash, Skin Toxicity 7. Diarrhea 8. Peripheral Neuropathy
30
What is the REMS program for Lenalidomide?
Slide 26
31
What are the counseling points for Lenalidomide?
Slide 27
32
What scores do we use to determine anticoagulation in multiple myeloma?
IMPEDE + SAVED
32
When is the risk of a thrombotic event highest with multiple myeloma?
Within 6 months of diagnosis.
33
If a patient has an IMPEDE score 4+ and 2+ saved, waht anti coagulation is recommended?
1. Enoxaparin 40 mg QD 2. Apixaban 2.5 mg BID Rivaroxaban 10 mg QD, Fondaparinux 2.5 mg QD, Warfarin INR 2-3
34
What anticoagulation is preferred if IMPEDE <3 or <2 SAVED?
Aspirin 81-325 mg QD
35
When is Cylcophosphamide used in multiple myeloma induction?
When emergent treatment is needed or in poor renal function.
36
What is the induction regimen containing cyclophosphamide?
Slide 31
37
What does NCCN say about bisphosphonates in cancer treatment?
Slide 34
38
What are the preferred doses of Zoledronic Acid and Denosumab?
Slide 35
39
What is the preferred agent for herpes and varicella?
Acyclovir 400 mg PO BID ---> renally adjusted
40
What are the preferred bacterial prophylaxis?
1. Levofloxacin 500 mg QD ---> Renally dose adjusted ---> Significantly reduced febrile episodes with no difference in C. Dif, MRSA, Antibiotic resistant organisms or tendonitis..
41
When do we cover hepatitis prophylaxis in multiple myeloma?
If they have positive core and antigen (NOT ANTIBODY POSITIVE)
42
What agent is used for hepatitis B prophylaxis?
Entecavir 0.5 mg QD
43
What is the continued treatment after induction?
Slide 37
44
What does V stand for?
Velcade: Borteozomib
45
What does R stand for?
Lenalidomide
46
What does C stand for?
Cyclophosphamide
47
What is VRd?
Velcade (Borteozomib) R: Lenalidomide D: Dexamethasone
48

J:Breast Cancer (6 decks)

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