Therapeutic Advancements in Multiple Myeloma - Episode 4

Supportive Care for Multiple Myeloma

There have been many advances in the primary treatment of multiple myeloma that have prolonged the overall survival of patients with this disease many-fold. The immunomodulatory drugs, proteasome inhibitors, monoclonal antibodies are utilized in combination both initially and to treat relapsed disease, which have resulted in myeloma often becoming a chronic disease and patients living their normal lifespan, growing old and dying from something else. As a consequence, we really do need to be cognizant of the short-term and long-term complications and their need for supportive therapies.

The reasons for supportive therapies can be both disease-related and also treatment-related complications. So you all know the most common supportive therapy is that for bone disease and multiple myeloma with the bisphosphonates that have been utilized since the early 1990s, but importantly, in patients who have renal dysfunction.

the ability now to use denosumab in such patients and decrease bony complications has been a major advance in our disease. A major other point to raise here is that the use of monoclonal antibodies, in particular CD38 monoclonal antibodies, can in some patients predispose them to infections, both in the short-term and in the long-term. As you know, patients with myeloma have, as part of their disease, a predisposition to infection and are immunocompromised, both humoral and cellular deficit in patients. For example, those who are on CD38 antibodies over long periods of time, there can be depletion of their normal immunoglobulins. In such patients, intravenous immunoglobulin is often given monthly, particularly in the winter months to avoid the complications of therapy. And then, what's so exciting in myeloma is we have multiple novel agents. So if patients have come up with complications, we can avoid them. For example, in patients with neuropathy, we would not use bortezomib (Velcade). We would choose carfilzomib (Kyprolis), the proteasome inhibitor that doesn't cause neuropathy, but in patients who do have neuropathy as part of their underlying disease, we have strategies now, primarily to treat symptomatically or to alter our therapy to decrease the likelihood of neurologic complications. The example I'd cite there is bortezomib, which was originally used intravenously twice a week for 2 weeks with a week off, is now used around the world subcutaneously and weekly, because in so doing, you minimize the complications and the need for supportive care.

So I think it's important to sort of sum this up and say that we've made parallel advances in the supportive care of myeloma along with the primary advances of treatment. This is so important because as we prolong the duration of life, we really need to be sure that this is also accompanied by a concomitant improvement in their quality of life as well.