Supportive therapy for multiple myeloma

Supportive therapy is an important part of treatment for multiple myeloma. It is given to treat complications from treatments and the multiple myeloma itself. Some of these complications can include bone loss, low blood cell counts and infection.

Corticosteroids used to treat multiple myeloma are artificial steroid hormones. The corticosteroids most often used to treat multiple myeloma are prednisone and dexamethasone. These drugs are often combined with chemotherapy or targeted therapy or both to help the treatment work better.

Corticosteroids are sometimes used alone if a person is too sick to have treatment to help slow the growth of myeloma cells and lower the amount of M-protein in the blood.

Corticosteroids can also help relieve pain and improve nerve function in people with spinal cord compression.

Multiple myeloma can destroy bone. This can cause bones to become weak and even break (called a fracture).

Bisphosphonates are drugs that can slow down bone destruction, help keep bones strong and help reduce bone pain. They also help prevent high levels of calcium in the blood (called hypercalcemia) from bone destruction, which can lead to kidney failure.

Bisphosphonates are given every 3 to 4 weeks for about 2 years. The most common bisphosphonates used for multiple myeloma are:

• pamidronate
• zoledronic acid (Aclasta, Zometa)

If after 2 years the cancer is in remission or you are on maintenance therapy, you may have bisphosphonate treatment less frequently (for example, once every 3 months). The dose and length of time you are taking bisphosphonates depends on your specific situation.

A drug called denosumab (Prolia, Xgeva and biosimilars) may be used to reduce the risk of bone problems in people with multiple myeloma. It helps slow down or stop bone loss. Denosumab is a monoclonal antibody that finds and attaches to RANKL, which is a substance on the surface of bone cells. RANKL helps break down bones. When RANKL is targeted and blocked, bones are not broken down as quickly. Denosumab can be used instead of bisphosphonates if your kidneys are not working properly.

You may also be prescribed calcium and vitamin D supplements by your doctor to help strengthen your bones if you don't have hypercalcemia.

Bisphosphonates and denosumab can lead to death of the jawbone, a condition called osteonecrosis of the jaw. This is a rare side effect of these drugs. Osteonecrosis is more common if you have dental surgery such as pulling teeth or periodontal surgery such as implants while you are taking bisphosphonates or denosumab.

You should have a complete dental exam before taking bisphosphonates or denosumab. Dental or periodontal surgery should be done before taking bisphosphonates. It is also very important to have regular dental checkups and maintain good oral health practices while taking bisphosphonates or denosumab.

Learn more about bisphosphonates.

Low red blood cell counts (also called anemia) is common in people with multiple myeloma. Erythrocyte growth factors are drugs that help the body make more red blood cells. These drugs include epoetin alfa (Eprex) and darbepoetin (Aranesp). Erythrocyte growth factors can help relieve the symptoms of anemia including weakness, dizziness and fatigue. They also improve the hemoglobin level in your blood and your quality of life. You may also be given an iron supplement or have red blood cell transfusions to help manage anemia. Erythrocyte growth factors can increase the risk of blood clots (thrombosis), especially when given in combination with immunomodulating drugs such as lenalidomide.

Multiple myeloma and its treatments can lower your white blood cell count. Granulocyte colony-stimulating factors (G-CSFs) may be used to stimulate the production of white blood cells. This shortens the length of time you will have a low white blood cell count and lowers the risk of infection. Growth factors used in supportive therapy for multiple myeloma may include filgrastim (Neupogen, Grastofil) and pegfilgrastim (Neulasta). These drugs may be given as an injection just under the skin (subcutaneously) or through a needle in your vein (intravenously).

Multiple myeloma and its treatment can affect your immune system and increase your risk for serious infections. Antibiotics, such as levofloxacin, sulfamethoxazole/trimethoprim and acyclovir (Sitavig), may be given to prevent and treat common infections such as pneumonia and herpes zoster.

To help prevent serious bacterial infections, you may receive immunoglobulin replacement therapy. Immunoglobulin replacement therapy helps to raise the level of immunoglobulins (also known as antibodies) in the blood to help fight infections. To have this therapy, you will need to meet certain criteria set by your province or territory. It is usually given as a blood product transfusion of immunoglobulins through a needle in a vein (called intravenous immunoglobulin, or IVIG).

Your doctor may also recommend that you be up to date with all of your immunizations. These include influenza (flu), pneumonia and shingles vaccines. You may also need additional vaccines if you had a stem cell transplant.

People with multiple myeloma are often severely affected by COVID-19 and are at a greater risk of dying from it. The COVID-19 vaccine has also been known to not be as effective in people with multiple myeloma. Your doctor may recommend you receive COVID-19 vaccine boosters as soon as you are eligible in your province or territory. You may also be encouraged to wear a well-constructed and well-fitting mask made of multiple layers and practise physical distancing as much as you can when you are in indoor public spaces. If you have signs or symptoms of COVID-19, test yourself as soon as possible. Talk to your doctor right away if you have COVID-19 so you can be assessed for treatment.

M-protein is an immunoglobulin that is found in high amounts in a person with multiple myeloma. Too much M-protein in the blood can cause the blood to thicken and prevent it from moving through the body properly. This condition is called hyperviscosity.

Plasmapheresis is a procedure that helps remove M-protein from the blood to treat thick blood.

To make the decisions that are right for you, ask your healthcare team questions about treatment. For more detailed information on specific drugs, go to sources of drug information.