health topics

What Is the Most Common Treatment for Multiple Myeloma?

There are many different types of treatment for multiple myeloma. Typically two or three drug combinations will be used to treat multiple myeloma. Common drug therapies include proteasome inhibitors, immunomodulating drugs, steroids, histone deacetylase (HDAC) inhibitors, Monoclonal antibodies, chemotherapy, induction therapy, and a nuclear export inhibitor.
There are many different types of treatment for multiple myeloma. Typically two or three drug combinations will be used to treat multiple myeloma. Common drug therapies include proteasome inhibitors, immunomodulating drugs, steroids, histone deacetylase (HDAC) inhibitors, Monoclonal antibodies, chemotherapy, induction therapy, and a nuclear export inhibitor.

Multiple myeloma is a type of cancer of the blood for which there are numerous treatments. Multiple myeloma treatment may be systemic (affects the entire body) or local (directed at the tumor without affecting the entire body). 

Systemic treatments for multiple myeloma reach cancer cells throughout the body. Common drug therapies used to treat multiple myeloma include: 

  • Proteasome inhibitors 
    • Bortezomib (Velcade) 
    • Carfilzomib (Kyprolis) 
    • Ixazomib (Ninlaro) 
  • Immunomodulating drugs 
    • Lenalidomide (Revlimid) 
    • Pomalidomide (Pomalyst) 
    • Thalidomide (Thalomid) 
  • Steroids such as dexamethasone and prednisone
    • May be used alone or combined with other drugs 
    • Also used to help decrease nausea and vomiting caused by chemo 
  • Histone deacetylase (HDAC) inhibitors 
    • Panobinostat (Farydak)
  • Monoclonal antibodies 
    • Elotuzumab (Empliciti) 
    • Daratumumab (Darzalex) or a newer form of the drug, called daratumumab and hyaluronidase (Darzalex Faspro)
    • Isatuximab (Sarclisa) 
    • Antibody-drug conjugate: Belantamab mafodotin-blmf (Blenrep) 
    • Chimeric antigen receptor (CAR) T-cell therapy: idecabtagene vicleucel (Abecma) 
  • Chemotherapy
    • Cyclophosphamide (Cytoxan)
    • Etoposide (VP-16)
    • Doxorubicin (Adriamycin)
    • Liposomal doxorubicin (Doxil)
    • Melphalan flufenamide, also called melflufen (Pepaxto)
    • Melphalan (Evomela) 
    • Bendamustine (Treanda)
    • Vincristine (Oncovin)
  • Nuclear export inhibitor 
    • Selinexor (Xpovio)

Although a single drug may be used to treat multiple myeloma, it is preferable to use at least two or three different kinds of drugs in combination because the cancer responds better. The combination of a proteasome inhibitor and an immunomodulatory agent plus the steroid dexamethasone is the standard treatment for newly diagnosed patients.

  • In the U.S., the most commonly used induction therapy for healthy, transplant-eligible patients is called VRd, which is a combination of bortezomib (Velcade), lenalidomide (Revlimid), and low-dose dexamethasone 

Other induction therapies include the following:

  • Bortezomib (Velcade), cyclophosphamide (Cytoxan), and dexamethasone (called VCD or cybord)
  • Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (called VTD)
  • Lenalidomide (Revlimid), and dexamethasone (called Rd)
  • Bortezomib (Velcade), and dexamethasone (called Vd)
  • Reduced dose and schedule of bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone (called Vrd Lite)

Other types of drugs used to treat multiple myeloma include: 

  • Bisphosphonates for bone disease
    • Pamidronate (Aredia)
    • Zoledronic acid (Zometa) 
    • Denosumab (Xgeva, Prolia)

Other systemic treatments for multiple myeloma include: 

  • Stem cell transplant 
    • Autologous stem cell transplant should be considered early in all transplant-eligible patients
  • Supportive treatments 
    • Intravenous immunoglobulin (IVIG) to help prevent infections
    • Treatment for low blood cell counts
      • Epoetin (Procrit) 
      • Darbepoetin (Aranesp) 
    • Plasmapheresis is used to remove myeloma protein from the blood

Local treatments for multiple myeloma are often used to treat earlier stage cancer, though they are sometimes used in other situations, and may include: 

  • Surgery 
    • May be used to remove single plasmacytomas (rarely used to treat multiple myeloma)
    • May also be used when spinal cord compression causes paralysis, severe muscle weakness, or numbness
    • Metal rods or plates may be surgically attached to help support weakened bones and or to prevent or treat fractures
  • Radiation therapy
    • May be used to treat areas of bone damaged by myeloma that have not responded to chemotherapy and/or other drugs 
    • The type of radiation therapy most often used to treat multiple myeloma is external beam radiation therapy

What Are Symptoms of Multiple Myeloma?

Multiple myeloma does not cause symptoms in everyone. When symptoms do occur, they may include:

  • Bone problems
    • Bone pain, commonly in the back, hips, and skull
    • Osteoporosis
    • Bone weakness where there is a plasmacytoma
    • Fractures 
  • Low blood counts of red blood cells (anemia), white blood cells (leukopenia), or plasma cells (thrombocytopenia)
  • High blood levels of calcium (hypercalcemia)
  • Nervous system symptoms 
    • The bones in the spinal cord can weaken and result in spinal cord compression, a medical emergency. See a doctor right away if you experience: 
      • Sudden severe back pain
      • Numbness or muscle weakness, usually in the legs
  • Nerve damage 
    • Numbness 
    • Weakness
    • “Pins and needles” sensation
  • Thickened blood (hyperviscosity) that slows blood flow to the brain
    • Dizziness
    • Confusion
    • Stroke symptoms, such as weakness on one side of the body and slurred speech
  • Kidney problems
    • Shortness of breath
    • Leg swelling
    • Itching
    • Weakness
  • Infections, such as pneumonia

How Is Multiple Myeloma Diagnosed?

Multiple myeloma is diagnosed with a patient history and physical examination, a combination of blood tests, urine testing, and imaging tests. 

Lab tests used to diagnose multiple myeloma include: 

  • Blood tests
    • Beta-2 microglobulin
    • Blood chemistry 
    • Complete blood count (CBC) 
    • Electrophoresis
    • Levels of blood creatinine, albumin, calcium, and other electrolytes
    • Lactic dehydrogenase (LDH) levels 
    • Quantitative immunoglobulins
    • Serum free light chains
  • Urine tests 
  • Biopsies
  • Imaging tests
    • Bone X-rays
    • Magnetic resonance imaging (MRI) scans
    • Computed tomography (CT) scan
    • Positron emission tomography (PET) scans
    • Echocardiogram (“echo”) of the heart

A diagnosis of multiple myeloma requires:

  1. A plasma cell tumor (proven by biopsy) OR at least 10% plasma cells in the bone marrow, AND
  2. At least one of the following:
  • High blood calcium level
  • Low red blood cell counts (anemia)
  • Poor kidney function
  • Holes in the bones from a tumor noted on imaging studies 
  • Increase in one type of light chain in the blood so that one type is 100 times more common than the other
  • 60% or more plasma cells in the bone marrow
References
https://www.cancer.org/cancer/multiple-myeloma.html

https://themmrf.org/multiple-myeloma/treatment-options/standard-treatments/

https://www.myeloma.org/frontline-treatment-options