Nursing Care for a Patient With

Multiple Myeloma
Sandra E. Kurtin, RN, MS, AOCN,
ANP-C
Hematology/Oncology Nurse Practitioner
Clinical Assistant Professor of Nursing
Clinical Assistant Professor of Medicine
Arizona Cancer Center
University of Arizona
Tucson, Arizona
This program is supported by educational grants from

Nursing Care for a Patient With Multiple Myeloma
clinicaloptions.com/oncology

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Nursing Care for a Patient With Multiple Myeloma
clinicaloptions.com/oncology

Faculty
Sandra E. Kurtin, RN, MS, AOCN, ANP-C
Hematology/Oncology Nurse Practitioner
Clinical Assistant Professor of Nursing
Clinical Assistant Professor of Medicine
Arizona Cancer Center
University of Arizona
Tucson, Arizona

Disclosure
Sandra E. Kurtin, RN, MS, AOCN, ANP-C, has disclosed
that she has received fees for non-CME/CE services from
Celgene, Millennium, and Onyx.

Introduction:
Overview of MM

Nursing Care for a Patient With Multiple Myeloma clinicaloptions.com/oncology Overproduction of Abnormal Plasma Cells and Associated Serum Proteins in MM Renal impairment Cytopenias MM bone marrow Myeloid progenitor cell Invasion of bone Hematopoietic stem cell T lymphocytes marrow Lymphoid Genetic progenitor cell and molecular defects NK cells B lymphocytes Invasion of bone ↑ circulating abnormal Lytic lesions serum proteins hypercalcemia Immunodeficiency Abnormal plasma cells neurological disease NIH. Image created by Sandy Kurtin. The University of Arizona Cancer Center. 2009. . Stem cell basics.

electrolytes ISS  Cytogenetics − Serum calcium (corrected) Salmon-Durie staging system  FISH Estimate prognosis − Serum albumin Cytogenetics − β2-microglobulin Albumin − LDH β2-microglobulin − Additional testing based on Ploidy preliminary analysis Identify need for immediate intervention Radiology Severe hypercalcemia  Skeletal survey Acute renal failure  MRI if vertebral compression fractures suspected Cord compression  PET/CT Severe pain or impending fracture NCCN.1:19-29.2. . Kurtin S. v. % − SFLC assay (kappa.2013. lambda) Solitary plasmacytoma − Cellularity  24-hr urine Determine stage − Ploidy − BUN. JAdPrO. differential and platelet count MGUS Smoldering Additional laboratory tests Bone marrow biopsy and aspiration Active  Serum immunoglobulins  Hematopathology Determine subtype − Quantitative (IgG. IgD) Heavy chain/light chain − Presence of plasma − SPEP Nonsecretory cells.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. IgA.com/oncology MM Diagnostic Evaluation History and physical Establish diagnosis of MM CBC. 2010. IgM. Clinical practice guidelines in oncology: multiple myeloma. creatinine.

2010. Adapted with permission from Kurtin SE. et al.4:379-398.5 mg/L or ULN progression to MM progression to MM in the first 5 yrs R: Renal dysfunction (serum creatinine > 2 mg/dL) A: Anemia (Hb <10 g/dL or 2 g < normal) B: Bone disease (lytic lesions or osteoporosis) Kuehl WM. et al. Hematol J. Clin Cancer Res. et al. J Adv Pract Oncol. Leukemia.com/oncology MM Disease Trajectory Nonmalignant Aggressive and Accumulation Malignant Transformation Stromal Independent Plasma Stroma and IL-6 angiogenesis dependent cell leukemia MGUS Smoldering Myeloma Multiple Myeloma  < 3 g M protein  ≥ 30 g/L M protein  ≥ 10% clonal BMPC  < 10% clonal BMPC  ≥ 10% clonal BMPC  M protein in serum and/or urine  No MM-related  No MM-related  ≥ 1 CRAB features of disease related to end-organ damage end-organ damage organ damage  1%/yr risk of  10%/yr risk of C: Calcium elevation > 11. . et al.2:175-187. 2006. Vacca A.19:985-994. 2002. Durie BG.1:19-29. 2013.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Agarwal A. Nat Rev Cancer. 2003.20:193-199.

5 g/dL and albumin ≥ 3.23:3412-3420.5 g/dL Calcium normal or ≤ 12 mg/dL Normal skeletal survey or solitary plasmacytoma Low M protein production  IgG < 5 g/dL  IgA < 3 g/dL Bence Jones protein < 4 g/24 h II Neither stage I nor stage III III 1 or more of the following β2M ≥ 5.36:842-854. . Cancer. 2. Greipp PR.com/oncology MM Staging Systems Stage Durie-Salmon Staging System[1] International Staging System[2] I Hemoglobin > 10 g/dL β2M < 3. et al. et al. 2005. 1975. Durie BG.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.5 g/dL  Calcium > 12 mg/dL  Multiple lytic bone lesions  High M protein component – IgG > 7 g/dL – IgA > 5 g/dL – Bence Jones protein > 12 g/24 hrs 1.5 g/dL  Hb < 8. J Clin Oncol.

2009. 2005. Kumar SK. Mayo Clin Proc.5 to 5. Mos I β2M < 3.5 mg/L 62 Albumin ≥ 3. et al. J Clin Oncol.4 mg/L 44 Albumin < 3.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. et al.5 g/dL III β2M ≥ 5.5 mg/L 29 Greipp PR.23:3412-3420. .84:1095-1110.com/oncology International Staging System Stage Characteristic Median Survival.5 g/dL II β2M 3.

Risk-Adapted Treatment for MM .

.com/oncology Treatment of Multiple Myeloma Confirmed Diagnosis of Multiple Myeloma—CRAB Criteria Determination of Immediate interventions for transplantation eligibility serious adverse events Individualized Treatment Selection for Induction Therapy Transplantation Eligible Transplantation Ineligible Works rapidly (CR. v.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.2013.2. Clinical practice guidelines in oncology: multiple myeloma. VGPR) Achieving a CR or nCR Well tolerated Level of evidence 1 or 2A Spares stem cells Tolerability and QoL Level of evidence 1 or 2A PS and comorbidities Continued Treatment Salvage therapy Maintenance therapy NCCN. nCR.

Nursing Care for a Patient With Multiple Myeloma clinicaloptions.com/oncology Treatment Options Have Greatly Increased in the Past Decade MM Therapies Introduction FDA Approved in MM 1950 1960 1970 1980 1990 2000 2010 1958 1983 2003 Melphalan Autologous Bortezomib 3rd line 2013 transplantation Pomalidomide 3rd line 1962 2005 Prednisone Bortezomib 2nd line 1986 2012 1969 High-dose 2006 Carfilzomib Melphalan + dexamethasone Lenalidomide + dex 3rd line prednisone 2nd line 2012 Bortezomib SC 2006 Thalidomide + dex 2008 1st line Bortezomib frontline 2007 Doxorubicin + bortezomib 2nd line .

3 2001-2005 63 31 0.1 0 0 1 2 3 4 5 6 7 8 9 10 Follow-up From Diagnosis (Yrs) Kumar SK.0 Proportion of Pts Surviving Median 7.2 2001-2005 0.6 2006-2010 ≤ 65 Yrs > 65 Yrs 0.4 2006-2010 73 56 0.8 0. . et al. Abstract 3972. % 0.7 5-Yr Survival by Age.9 0. Nursing Care for a Patient With Multiple Myeloma clinicaloptions.com/oncology MM Survival Is Improving With Novel Agents 1.5 0. ASH 2012.3 yrs 0.

VRD.com/oncology Changing Treatment Paradigm: Combinations Common Myeloma Regimens* Combination Abbreviation(s) Bortezomib/dexamethasone VD or Vd Bortezomib/cyclophosphamide/dexamethasone CyBorD  Rationale: combination Transplant Bortezomib/doxorubicin/dexamethasone therapies demonstrated Primary Induction Bortezomib/lenalidomide/dexamethasone VRD or VRd improved response rates. and/or OS compared Lenalidomide/dexamethasone RD or Rd Carfilzomib/lenalidomide/dexamethasone with single agents Bortezomib/dexamethasone VD or Vd  Nursing considerations transplant Lenalidomide/dexamethasone RD or Rd Non- Melphalan/ prednisone/bortezomib VMP or MPB – AE management Melphalan/prednisone/lenalidomide MPR or MPL Melphalan/prednisone/thalidomide MPT – Patient adherence Repeat primary induction (if relapse > 6 mos) – Performance status Pomalidomide + dexamethasone (most preferred) Bortezomib  dexamethasone  lenalidomide V. Vd. Bortezomib/thalidomide/dexamethasone VTD or VTd PFS. VD. v.com/OncTools High-dose cyclophosphamide Thalidomide/dexamethasone TD or Td for treatment tool *Preferred regimens according to NCCN. Clinical practice guidelines in oncology: multiple myeloma.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.2013. .2. VRd – Frailty Bortezomib/liposomal doxorubicin Salvage Regimens Bortezomib/thalidomide/dexamethasone VTD or VTd – Renal function Lenalidomide/dexamethasone RD or Rd – Other comorbidities Carfilzomib Cyclophosphamide/lenalidomide/dexamethasone – Patient preference Dexamethasone/cyclophosphamide/etoposide/cisplatin DCEP Dexamethasone/thalidomide/cisplatin/doxorubicin/cyclophos DT-PACE  See phamide/etoposide  bortezomib VTD-PACE clinicaloptions.

every 28 days  Dose modifications for cytopenias. Lenalidomide [package insert]. 8. Thalidomide [package insert]. every 21 days x 2 cycles. 4. cytopenias Pomalidomide[4]/  4 mg/day on Days 1-21 using a 28 day cycle immunomodulatory agent  Dose modifications for cytopenias Thalidomide[5]/  200 mg/day by mouth at bedtime immunomodulatory agent  Variable dosing in combination regimens  Dose modification for neuropathy. 9. Pomalidomide [package insert]. Bortezomib [package insert]. . 5. proteasome inhibitor 16.3 mg/m2 IV or SC on Days 1. 11.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. 2. 3. proteasome inhibitor then weekly dosing 3 wks on/1 wk off  Variable dosing in combination regimens  Dose modification for neuropathy. 4. 27 mg/m2 (cycles 2-12) on Days 1. cytopenias 1. 2. cytopenias Carfilzomib[2]/  20 mg/m2 IV (cycle 1). cardiopulmonary symptoms Lenalidomide[3]/  25 mg/day by mouth for induction immunomodulatory agent  Variable dosing in combination regimens  Dose modification based on renal function.com/oncology Common Dosing Regimens for Novel Therapies Agent/Class Dosing and Route of Administration Bortezomib[1]/  1. 8. Carfilzomib [package insert]. 15.

et al. Am J Hematol. Hematologica. 2011. 2012.20) (MAF-B)  t(11.16) (C-MAF)  Hyperdiploidy  t(14.87:78-88.96:574-582. Complete Response Bortezomib Excellent appears critical critical outcome with novel agents Rajkumar SV.14) (FGFR3/MMSET) All others including  t(14.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.14) (CCND1)  High-risk GEP  t(6.14) (CCND3) signature *Presence of trisomies ameliorates high risk. Moreaux J. .com/oncology Risk-Stratification Based on Tumor Biology High Risk* Intermediate Risk Standard Risk  17p deletion  t(4.

J Adv Pract Oncol. et al.com/oncology Common Disease-Related and Treatment- Emergent Adverse Events  Myelosuppression*. 2013.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. In press. . neutropenia. Kurtin SE. all agents – Anemia. thrombocytopenia  Renal toxicities*  Hepatic toxicities  Neurotoxicity*  Nausea and vomiting  Constipation or diarrhea  Pain  Infection  Drug-specific treatment-emergent adverse events *May also be disease related.

4) neutropenia Neutropenia: 17. 2013.3 (3. (3) Dyspnea: 34. J Adv Pract Oncol.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.6) Peripheral edema: 11 Varicella zoster: 2 Infectious complications Varicella zoster: 13-20 Pneumonia: 12.2) Gastrointestinal Overall: 52 (8) Diarrhea: 32. 2011.9 (1. N Engl J Med. Kurtin SE.6) Diarrhea: Constipation: 20.3 (23. % Thrombocytopenia and Thrombocytopenia (cyclic): 36 (29) Thrombocytopenia: (cyclic): 36. Bortezomib [package insert].7 (1. (12) Neutropenia: 20. Bortezomib Carfilzomib Relapsed/Refractory All Grades (Grade 3/4).0 (0.5 (7. et al.7 (10.7 (10. no grade 4) Weekly SC: 24 (6) Fatigue Overall: 64 (16) Overall: 55. Carfilzomib [package insert].5) Renal dose adjustment recommended for Renal dose modification No renal dose adjustment required creatinine ≥ 2 x baseline Thromboembolic events Not reported* Not reported* Rash Not reported* Not reported* *Data not available or incidence was below threshold for reporting.1) Hypotension: 13 Cardiopulmonary Hypertension: 14.3 ) Dyspnea: 11. et al.3) Congestive heart failure: 5 Peripheral edema: 24.9 (0. Palumbo A.6 (5.3) Twice weekly IV: 53 (16) Peripheral neuropathy Weekly IV: 41 (16) Overall: 14 (1% grade 3.com/oncology PIs: Common Adverse Events in MM Trials Adverse Events > 5% to 10%.364:1046- 1060. In press.0) Nausea: 57 (8) Nausea: 44. .

All Grades (Grade Dexamethasone) Dexamethasone) Dexamethasone) 3/4).0. Kurtin SE.364:1046-1060. . et al. J Adv Pract Oncol. Palumbo A. Pomalidomide [package insert].Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Thalidomide [package insert].com/oncology IMiDs: Common Adverse Events in MM Trials Adverse Events > 5% to Lenalidomide (With Thalidomide (With Pomalidomide 4 mg* (With 10%. Renal dose modification clinical trial in renal impairment under way Thromboembolic events Overall: 9. In press. et al.3 Overall: 23 Not reported* Rash Overall: 21 Overall: 30 Overall: 16 *Data not available or incidence was below threshold for reporting. % Relapsed/Refractory Thrombocytopenia and Thrombocytopenia: 21 (12) Thrombocytopenia: 23 Thrombocytopenia: 23 (19 ) neutropenia Neutropenia: 42 (33) Neutropenia: 31 Neutropenia: 47 (38) Not significant All grades: 54 (3-5) Overall: 7 (0) Peripheral neuropathy ↑ with higher doses and prolonged therapy Fatigue Overall: 43 (6) Overall: 81 (17) Overall: 63 (13) Constipation: 40 (3) Constipation: 56 (8) Diarrhea: 33 (0) Gastrointestinal Diarrhea: 38.5 (2) Nausea: 29 (5) Anorexia: 35 (0) Nausea: 26 (1) Nausea: 22 (0) Dyspnea: 23 (not reported) Dyspnea: 41 (13) Dyspnea: 45 (13) Cardiopulmonary Hypotension: 7 (not Peripheral edema: 57 (6) Peripheral edema: 16 (0) reported) Bradycardia reported Infectious complications Pneumonia: 14 Pneumonia: 35 Pneumonia: 29 (23) Requires renal dose No dose modification Dose modification should be adjustment required considered if creatinine > 3. 2011. Lenalidomide [package insert]. 2013. N Engl J Med.

Clinical practice guidelines in oncology: multiple myeloma.24:14-21. 2010. Oncology.24:7-13. Stadtmauer EA.2013. . Oncology.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. v. 2010.2.com/oncology How to Select Therapy for the Older Adult?  Goals of therapy – Early and sustained CR with an acceptable level of toxicity and improved QoL – Risk stratification including transplantation eligibility and individual patient factors Disease-Related Factors Patient-Related Factors High tumor burden Fit vs frail/vulnerability Renal failure Comorbidities: controlled vs uncontrolled Hypercalcemia Clotting or bleeding history Fractures Preexisting neuropathy Patient wishes Availability of a caregiver Niesvizky R. NCCN. et al.

hepatic. CA Cancer J Clin. controlled or uncontrolled Palumbo A. renal. housekeeping. . transfer. rheumatologic disease. and self-medication  Comorbidities – Cardiovascular. Frailty. and eat independently – IADLs: finances. toilet and maintain continence. Comorbidities.60:120-132.com/oncology Functional Status.118:4519-4529. 2010.5:224-237. severity. et al. endocrine. Balducci L. et al. and other cancers – Number. and Vulnerability  Functional status: measured by ECOG and Karnofsky PS – ADLs: ability to bathe. 2011.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Oncologist. transportation. 2000. dress. Kumar S. et al. pulmonary. shopping. Blood.

and frailty (fatigue.com/oncology Functional Status. weakness. disability (physical or mental impairment). Balducci L.0001)  Vulnerability – A complex of comorbidity (presence of chronic diseases or conditions).Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Kumar S. Blood. and death (P < . cognitive impairment. Oncologist. 2011. et al. 2000. low activity) that could prevent adequate therapy Palumbo A. poor nutritional intake. Frailty. and Vulnerability  Frailty – Weight loss. CA Cancer J Clin. . et al.60:120-132.118:4519-4529. 2010. Comorbidities. declining ADLs including diminished mobility.5:224-237. falls. and poor endurance – Cardiovascular Health Study (n = 5317): frailty associated with hospitalization. et al.

118:4519-4529. 22 q4w Days 1.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.3 mg/m2/wk 1. et al. 22 q4w Days 1. comorbidities. 15. Palumbo A. 4.0 mg/m2/wk Bortezomib Days 1. 22 q5w Days 1. 8. controlled vs uncontrolled. 8. 22 q5w 25 mg/day 15 mg/day 10 mg/day Lenalidomide Days 1-21 of 28-day Days 1-21 of 28-day cycle Days 1-21 of 28-day cycle cycle 40 mg/day 20 mg/day 10 mg/day Dexamethasone Days 1. depending on need for help and level of activity.18 mg/kg or 7. 8. 22 q4w 0.11 q3w Days 1. 15. 8. 2011.5 mg/m2 0.13 mg/kg or 5 mg/m2 Melphalan Days 1-4 q4-6w Days 1-4 q4-6w Days 1-4 q4-6w Thalidomide 100 mg/day 50 mg/day 50 mg QOD *Dosing based on risk factors including age. Blood.25 mg/kg or 9 mg/m2 0. 15.3 mg/m2 biweekly 1. 8. 8. 15. Patients grouped from very fit to severely frail.com/oncology Dose Adjustments for Age/Frailty Drug No Risk Factors* At Least 1 Risk Factor* At Least 1 Risk Factor* + Grade 3-4 Nonhematological AE 1. . 15.

.com/oncology Recommendations for Adjunctive Treatment  Bone disease*  Hypercalcemia – Bisphosphonates – Hydration. 2011.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. et al.15:9-23. furosemide – Monitor for osteonecrosis – Zoledronic acid preferred – Renal dosing required bisphosphonate – Treat for 2 yrs  Anemia – Radiation therapy – Consider erythropoietin – Orthopedic consultation – Caution in patients at high risk for thrombosis – Vertebroplasty or kyphoplasty – Transfusion  Hyperviscosity  Coagulation/thrombosis – Plasmapheresis – Prophylactic anticoagulation if treated with IMiDs *Included in the International Myeloma Foundation Nursing Leadership Board Survivorship Plan for MM NCCN.15:66-76. Clin J Oncol Nurs.2.2013. 2011. Clinical practice guidelines in oncology: multiple myeloma. Clin J Oncol Nurs. steroids. Faiman BM. v. Miceli TS. et al.

15:66-76. et al. Faiman BM. et al. . ongoing monitoring *Included in the International Myeloma Foundation Nursing Leadership Board Survivorship Plan for MM NCCN.2. herpes. and antifungal prophylaxis for high-dose or – Not a contraindication to HSCT long-term steroids – Monitor bisphosphonates – Herpes zoster prophylaxis for bortezomib-treated patients  Neuropathy – No live zoster vaccine – Requires dose adjustment for selected agents – Bortezomib SC vs IV – Baseline. Clin J Oncol Nurs.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. dehydration – PCP. 2011. NSAIDs. Clin J Oncol Nurs. Miceli TS.15:9-23.com/oncology Recommendations for Adjunctive Treatment  Infection  Renal dysfunction* – IVIG for recurrent infections – Dose modifications for selected regimens – Pneumococcus and influenza vaccines – Avoid aggravating factors: contrast. v.2013. Clinical practice guidelines in oncology: multiple myeloma. 2011.

Reconstituting For IV administration. especially in patients with renal compromise Shah GL.5 mg vial) 0. et al. Abstract E18553. ASH 2011. . et al. et al. ASH 2012. add 1. et al. ASCO 2012.com/oncology Bortezomib: SC vs IV Administration Subcutaneous (SC) Intravenous (IV)  FDA approved SC in 2012  FDA approved IV in 2003  Equivalent efficacy as IV (numerous  Highly effective myeloma therapy studies)  Neuropathy a notable AE  Reduced neuropathy.4 mL bortezomib add 35 mL 0. Abstract 1863. 2011. Moreau P.8% of patients prefer SC over IV – 54 min less “chair time” on average – 46 min less clinic time on average For SC administration.9% sodium chloride (3. Lancet Oncol.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.12:431-440. Barbee MS.9% sodium chloride Hydration: a key nursing consideration. Bortezomib [package insert]. GI AEs  67. Moreau P. Abstract 2968.

% CR.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.4 10.387 .com/oncology Phase III Study: Subcutaneous vs Intravenous Bortezomib Route and ORR. .4 53 16 SC (n = 145) 42 6 1.044 . 2011. Lancet Oncol. % Mos % IV (n = 73) 42 8 1. et al. Bortezomib [package insert].12:431-440.026  SC administration of bortezomib noninferior to IV (P = . Grades.4 9.4 38 6 P value .002)  Improved safety profile with bortezomib SC vs IV Moreau P. 3/4. % Median Median PN PN Administration Time to TTP. Mos All Grade Response.

seatbelt region. et al. swelling. Bortezomib [package insert]. or impaired Not studied for SC bortezomib skin integrity SC Thickness in Adults. minimum of 1 cm apart  Avoid: 2-cm region surrounding the umbilicus.3:406-410. areas prone to friction (eg. belt-line.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.com/oncology SC Bortezomib: Site Selection SC Injection-Site Selection Front Back  Adequate adipose tissue: “pinch an inch” using index finger and thumb  Rotate sites. etc). injecting into areas with scarring. and/or redness). Kurtin S. 2012. Abdomen 14 (2-30) 23 (6-58) pain. Sites for SC bortezomib inflammation. birthmarks. J Adv Pract Oncol. . hair follicles. median 6 Thigh 7 (2-22) 14 (5-34) days to resolve *Not included in pharmacokinetic studies for SC bortezomib. mm Male Female ~ 6% patients had injection Upper arm* 9 15 site reactions (itching.

Nursing Care for a Patient With Multiple Myeloma clinicaloptions.to 6-mm needles – 45° angle for ≥ 8-mm needle Use “air sandwich” technique  Remove needle promptly to avoid seeding of irritating  Apply gentle pressure to site medication in the injection track Kurtin S.com/oncology SC Bortezomib: Air Sandwich Technique “Air Sandwich” Technique  Attach fresh needle (4-6 mm) to syringe with prepared medication  Do not purge needle (air in needle)  Maximum volume for SC injection is 2 mL per site  Pull 0. 2012.5-1.3:406-410. et al.0 mL air into syringe  Use index finger and thumb to “pinch an inch”—avoid pinching the underlying muscle  Invert syringe and inject. J Adv Pract Oncol. . including air behind the drug – 90° angle for 4.

2010:437-444. 2012. Boyle EM. .com/oncology Thromboembolic Events  Cancer patients are at increased risk of TEE (4. Expert Rev Hematol. Hematology Am Soc Hematol Educ Program.5:617-626. 2010.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.to 5-fold)  Risk of mortality from a TEE is 2-fold higher in cancer patients  Individuals with advanced disease are at higher risk of TEE  Myeloma patients at highest risk at time of initial diagnosis Kristinsson SY.

Lenalidomide. and Pomalidomide Individual Risk Factors Actions  Obesity  LMWH (enoxaparin 40 mg/day or equivalent)  Previous VTE  Warfarin (target INR: 2-3)  Central venous catheter. 2012.119:933-999. . Expert Rev Hematol. Boyle EM. pacemaker  Associated diseases In general: − Cardiac − Chronic renal disease  Low risk (1 risk factor): patient should receive − Diabetes ASA 81-325 mg/day − Acute infection  High risk: patient should receive therapeutic − Immobilization prophylactic anticoagulation with LMWH. − Blood clotting disorders warfarin  Surgery. et al.5:617-626. Med Clin.139:31-35. 2012. or trauma  Medications MYELOMA IS A RISK FACTOR • ESAs Myeloma-Related Risk Factors  Diagnosis  LMWH (enoxaparin 40 mg/day or equivalent)  Hyperviscosity  Warfarin (target INR: 2-3)  Myeloma therapy − High-dose dexamethasone − Doxorubicin − Multiagent chemotherapy Trujillo Santos AJ. Larocca A. et al. anesthesia. 2012. Blood.com/oncology Thromboprophylaxis: Thalidomide.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.

Nursing Considerations for the Patient With Relapsed or Relapsed/Refractory MM .

com/oncology MM as a Chronic Disease  MM patients are living longer  Patients will be exposed to multiple therapies over the course of their disease  AHSCT remains an important treatment option but is not curative in the majority of patients  Relapse or progression is inevitable for most patients  Patients who fail first-line novel agents have a poor prognosis (~ 9 mos from time of relapse)  Response to salvage therapy for relapsed and refractory MM may be as short as 6 mos Kumar SK. 2012. 2010. Richardson PG. et al. Oncology. et al. .26:149-157. Leukemia.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.24:22-29.

Nat Rev Cancer. 2002. Durie BG. Community Oncol.2:175-187. et al.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Relapse M Protein (g/L) myeloma Refractory 50 1. et al.com/oncology Natural History of Multiple Myeloma Asymptomatic Symptomatic 100 Active 2.4:379-398. Relapse relapse MGUS or smoldering myeloma Plateau 20 remission First-line therapy Second-line Third-line therapy therapy Kuehl WM.6:12:22-29.myeloma. et al. 2003. Vacca A. Leukemia. et al.20:193-199.org. 2006. . Siegel DS. Adapted with permission from Durie B at www. 2009. Hematol J.

. other clones can Misc still exist Relapse 3 17% ~ 2N clg-high Relapse can occur when: 71% 66% clg-high 37% Existing clone no longer has to 95% 78% compete for space with the Plasma cell leukemia ~ 3N Relapse 4 formerly dominant clone clg-low ~ 3N 34% clg-low Acquires additional mutation(s) 96% 96% 63% providing a growth and/or survival advantage Keats JJ. especially after treatment rounds Clone 1.com/oncology Clonal Evolution and Clonal Competition 31% Multiple clones may be present at 64% 21% 9% the time of diagnosis 64% Remission ~ 2N Relapse 1 The predominant clone may ~ 2N change over time.1 Hypothesis: effective treatment Clone 1.120:1067-1076. et al.2 clone.1 72% Clone 2. Blood. 2012. Nursing Care for a Patient With Multiple Myeloma clinicaloptions.2 Relapse 2 10% 11% Diagnosis ~ 2N 19% 58% reduces or eliminates the dominant ~ 2N Clone 2. however.

often 2 or 3 novel agent combination regimens .Nursing Care for a Patient With Multiple Myeloma clinicaloptions.com/oncology Relapsed and Relapsed/Refractory MM  Relapse: development of clinically measurable disease or secondary organ effects after achieving a CR  Progression: development of clinically measurable signs of increased disease activity after achieving a PR or disease plateau – Progression of disease is implied in the term “relapsed”  Relapsed and refractory: defined as a lack of response or disease progression on or within 60 days of the last therapy – The therapy in use at the time of progression is what the patient is refractory to based on the dominant clone  Primary refractory: failure to achieve any response to specific MM treatments.

Salvage Therapy .

et al.2013. .Nursing Care for a Patient With Multiple Myeloma clinicaloptions. v.2.com/oncology MM Salvage Therapy: Clinical Guidelines Proteosome Inhibitor–Containing Regimens Bortezomib Bortezomib (category 1) Bortezomib/liposomal doxorubicin (category 1) Lenalidomide/bortezomib/dexamethasone Bortezomib/dexamethasone Cyclophosphamide/bortezomib/dexamethasone Dexamethasone/thalidomide/cisplatin/doxorubicin/cyclophosphamide/etoposide/ bortezomib Carfilzomib Single-agent carfilzomib* IMiD-Containing Regimens Lenalidomide Lenalidomide/bortezomib/dexamethasone Lenalidomide/dexamethasone (category 1) Pomalidomide Pomalidomide*/dexamethasone Thalidomide Thalidomide/dexamethasone Other Dexamethasone/cyclophosphamide/etoposide/cisplatin regimens Dexamethasone/thalidomide/cisplatin/doxorubicin/cyclophosphamide/etoposide *Indicated for patients with MM who have received ≥ 2 previous therapies (including bortezomib and an IMiD) and have progressed on/within 60 days of completing last therapy. In press. NCCN. 2013. J Adv Pract Oncol. Kurtin SE. Clinical practice guidelines in oncology: multiple myeloma.

v. Clinical practice guidelines in oncology: multiple myeloma.com/oncology Considerations in Selecting Salvage Therapy Time from previous therapy to  > 6 mos may use similar agents relapse or progression  < 6 mos: consider alternative agents in combination Refractory disease  Clinical trial enrollment  Newly FDA-approved agents pomalidomide or carfilzomib Reassess transplantation  Previous ASCT: second ASCT if TTP > 2 yrs options. including alloSCT on  Agents based on clinical trial − Time from previous therapy to relapse/progression − Any residual clinical conditions (neuropathy. NCCN. . et al.2013. 2010. Oncology. etc) Previous thalidomide  Bortezomib or bortezomib/PLD  Len/dex  High-dose dexamethasone/carfilzomib/pomalidomide Previous bortezomib  Thalidomide  Lenalidomide  Bortezomib/carfilzomib/pomalidomide Previous lenalidomide  Bortezomib  Bortezomib/PLD  Carfilzomib/pomalidomide Richardson PG. renal function.2.Nursing Care for a Patient With Multiple Myeloma clinicaloptions.24:22-29.

3 mg 2 yrs or until Grade 3/4 PNP: Only comparison between biweekly PD or 16% (IV PAD–ASCT bortezomib and intolerance administration) VAD–ASCT thalidomide available Thalidomide 50* (100) Up to 1 year. . tolerated. fatigue. and Poor tolerance in some patients mg/day no correlation other limiting dose (notably in elderly).com/oncology Treatment Paradigm Shift: Maintenance vs Continuous Therapy IMWG Consensus on Maintenance Therapy Drug Common Dose Duration Tolerance Comments or Regimen Lenalidomide 10* (5-15) Until PD or Few Unprecedented extension of mg/day intolerance discontinuations PFS. PNP. generally well on Days 1-21.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. 2012. et al. increased OS in 1 of 3 continuously or due to AEs studies. no benefit between and duration of in patients with FISH-defined duration and therapy high-risk profile outcome *Recommended Adapted from Ludwig H. but risk of second every 28 days malignancies increased Bortezomib 1. Blood. 119:3003-3015.

Vacca A. et al. Durie BG.com/oncology Natural History of Multiple Myeloma Asymptomatic Symptomatic 100 Active 2. .4:379-398. et al. et al. 2006. 2003.20:193-199.2:175-187. Relapse relapse MGUS or smoldering myeloma Plateau 20 remission First-line therapy Second-line Third-line therapy therapy Kuehl WM. Nat Rev Cancer. Relapse M Protein (g/L) myeloma Refractory 50 1. Adapted with permission from Durie B at www.myeloma. Hematol J. Community Oncol.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Leukemia. et al.6:12:22-29. 2009. Siegel DS. 2002.org.

com/oncology Relapsed and Refractory MM: General Principles  Treatment of patients with relapsed and refractory MM is complicated by the heterogeneity of the disease as well as adverse events of MM treatments  As proteasome inhibitors and IMiDs are now used more frequently in the upfront setting.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. novel salvage therapies are needed that are efficacious and well tolerated  2 novel agents have recently been approved – Pomalidomide – Carfilzomib .

gov.com/oncology Newly Approved Agents: Pomalidomide FDA approved: February 8. 2013 Pomalidomide Common AEs (in > 30%) Patients. tract infection 32 Back pain 32 – Take without food Pyrexia (pom + dex) 30 – At least 2 hrs before/after meals  Educate patients on – Do not break. chew. 2013. % Class: IMiD Fatigue and asthenia 55 Administration: oral Neutropenia 52 Constipation 36  REMS program Nausea 36 – Discuss administration with Diarrhea 34 patient : 4 mg once daily on Dyspnea 34 Days 1-21 of 28-day cycle Upper resp. FDA.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. . or open the capsules – DVT prophylaxis – Infection risk/blood counts – Adherence: consistent – Fatigue schedule (AM or PM) – Should not cause PN Pomalidomide [package insert].

diuretics.gov. FDA. 1st dose cycle 2 Thrombocytopenia 36 – Additional doses/cycles if infusion Dyspnea 35 reactions Diarrhea 33  Hydrate: 250-500 mL IV saline Pyrexia 30 – Before carfilzomib. 2012 Carfilzomib AEs (All Grades) Class: proteasome inhibitor Patients.com/oncology Newly Approved Agents: Carfilzomib FDA approved: July 20. which may include  Administer carfilzomib IV cardiopulmonary – 20 mg/m2 over 2-10 mins  The drug may require dose – Rinse IV with saline before and after adjustment for toxicities. after (optional) – Monitor for over hydration  Monitor AEs. 2012. inhalers. minimal PN Carfilzomib [package insert]. % > 30% Administration Fatigue 56  Premedicate: 4-mg dexamethasone Anemia 47 before carfilzomib Nausea 45 – All doses cycle 1.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. .

Fife BL. Stenberg U.com/oncology Selected Problems Faced by Patients With MM and Their Caregivers  Information – Provide detailed information about AEs of medication  Adherence – Provide calendar with treatment regimen and dates of administration to improve adherence  Inform patient and caregiver of symptoms – DVT/PE. Bone Marrow Transplant. infection.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Bone Marrow Transplant.48:469-473. et al. 2009. bleeding. 2013.19:1013-1025. et al.43:959-966. peripheral neuropathy. and neutropenia  Reinforce precautions Wulff-Burchfield. et al. . 2010. Psychooncology.

. McMullen L. Patient Educ Couns. etc) – Emphasize the importance of local and national support groups (transportation assistance. 2013. et al. dietary. reimbursement) Bensing J. Thorne S.Nursing Care for a Patient With Multiple Myeloma clinicaloptions. Semin Oncol Nurs. et al. 2013.90:291- 296.com/oncology Communication With Team Members  Communication with nursing staff – Improves quality of life – Reduces distress – Encourages active participation  Financial and social support – Treatment should NOT be compromised if patients lack financial or social support – Multidisciplinary cancer treatment team (social worker. Patient Educ Couns.90:287-290.29:105-117. 2013.

with expert faculty commentary clinicaloptions. Go Online for More CCO Coverage of Multiple Myeloma! Capsule Summaries of all the key data.com/MyelomaNursing . plus Expert Analysis panel discussions exploring the clinical implications Additional CME-certified slidesets on current myeloma treatment.

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