Seasons of Multiple Myeloma
Tiffany Richards, MS, ANP, AOCNP, FRCPC, FACP, MD
Anderson
Wintery Mix of Treatment Options Spring into Managing Side Effects
Summer of Success
Wintery Mix of Treatment Options
Diverse and Complex Treatment Combinations
Myeloma Treatment Common Combinations
Velcade® (bortezomib) DVRd, VRd, Vd
Lenalidomide DVRd, VRd, Rd
Kyprolis® (carfilzomib) KRd, Kd, DKd, Isa-Kd
Pomalyst® (pomalidomide) Pd, DPd, EPd, PCd, Isa-Pd
Darzalex® (daratumumab) DVRd, DRd, DVd, DPd, DVMP, DKd
Ninlaro®(ixazomib) IRd
Empliciti® (elotuzumab) ERd, EPd
Xpovio® (Selinexor) XVd, XPd, XKd
Sarclisa® (Isatuximab) Isa-Kd, Isa-Pd
Blenrep® (Belantamab mafodotin) Bela-d
Abecma® (Idecabtagene Vicleucel) --
Carvykti™ (ciltacabtagene autoleucel) --
Elrexfio™ (elranatamab)
Tecvayli® (teclistamab) --
Talvey™ (talquetamab) --
Venclexta® (venetoclax) Vd + ven
New agents or regimens in clinical trials are possible options
ASCT = autologous stem cell transplant; Bela = belantamab; C = cyclophosphamide; D = daratumumab; d = dexamethasone; E = elotuzumab; Isa = isatuximab; I = ixazomib; K = carfilzomib; M = melphalan; P = pomalidomide; R = lenalidomide; V = bortezomib; ven = venetoclax.
Stem Cell Transplant
ELIGIBILITY
Measuring Treatment Response
Determining Transplant
Eligibility
Insurance Authorization
Collecting Stem Cells
TRANSPLANT
High Dose Chemotherapy Stem Cell Infusion
Supportive Care
Engraftment
P H A S E 1 P H A S E 2 P H A S E 3
Duration: Approximately 2 weeks
Location: Transplant Center
Duration: Approximately 3-4 weeks
Location: Transplant Center
POST-TRANSPLANT
Restrengthening
Appetite recovery
“Day 100” assessment
Begin maintenance therapy
Duration: Approximately 10-12 weeks
Location: HOME
CAR T: Another Treatment Approach
Ask for a referral to CAR Tcell center as soon as it is possible as next treatment option (ie, before relapse)
No driving for 8 weeks
“One & Done” with continued monitoring
T-Cell Collection
Manufacturing takes
≈ 4 to 6 weeks
Bridging therapy may be needed
• Away from home
• Often some hospital stay
• Care Partner needed
• Side effect management
• CRS, ICANS
• Low blood counts
• Fatigue and fever
• Some patients need ongoing transfusion support
Bispecific Antibodies
• Different bispecific antibodies have differences in efficacy, side effects
• Available after 4 prior lines of therapy (or clinical trial)
• About 7 in 10 patients respond
• Off-the-shelf treatment; no waiting for engineering cells
• CRS and neurotoxicity
• Risk of infection
• BCMA target: greater potential for infection
• Tecvayli® (teclistamab)
• Elrexfio™ (elranatamab)
BISPECIFIC ANTIBODIES
• GPRC5D target: potential for skin and nail side effects, GI issues of taste change, anorexia and weight loss
• Talvey™ (talquetamab)
CAR T and Bispecific Antibodies: Unique Side Effects
Cytoki ne Releas e Syndro
CRS is a common but often mild & manageable side effect
CAR = chimeric antigen receptor; CRS = cytokine release syndrome. Oluwole OO, Davila ML. J Leukoc Biol. 2016;100:1265-1272. June CH, et al. Science. 2018;359:1361-1365. Brudno JN, Kochenderfer JN. Blood. 2016;127(26):3321-3330. Brudno JN, Kochenderfer JN. Blood Rev. 2019:34:45-55. Shimabukuro-Vornhagen, et al. J Immunother Cancer. 2018;6:56. Lee DW, et al. Biol Blood Marrow Transplant. 2019;25:625-638.
CAR T and Bispecific Antibodies: Unique Side Effects
Spring Into Managing Side Effects
The Early Bird Gets the Worm: Communicate
Proactively with Your Healthcare Team
Your team may be able to help,
Unmanaged Myeloma can cause:
• Calcium elevation
• Renal dysfunction
• Low blood counts
• Infection Risk
• Blood clots
• Bone pain
• Neuropathy
• Fatigue
but only if they know how you feel.
Side Effects of Treatment can
cause:
• GI symptoms
• Renal dysfunction
• Low blood counts
• Infection Risk
• Blood clots
• Neuropathy
• Fatigue
How You Feel
Tip: Keep a Symptom Diary and bring it to appointments
Tip: proactively discuss common side effects and what to do if they occur
Are Steroids Messing With Your Sunny Disposition?
Steroids enhance the effectiveness of other myeloma therapies
Your provider may adjust your dose. Do not stop or alter your dose of steroids without discussing it with your provider
Managing Steroid Side Effects
• Consistent schedule (AM vs. PM)
• Take with food
• Stomach discomfort: Over-thecounter or prescription medications
• Medications to prevent shingles, thrush, or other infections
Steroid Side Effects
• Irritability, mood swings, depression
• Difficulty sleeping (insomnia), fatigue
• Blurred vision, cataracts
• Flushing/sweating
• Increased risk of infections, heart disease
• Muscle weakness, cramping
• Increased blood pressure, water retention
• Stomach bloating, hiccups, heartburn, ulcers, or gas
• Weight gain, hair thinning/loss, skin rashes
• Increased blood sugar levels, diabetes
Infection Can Be Serious for People With Myeloma
[P]reventing infections is paramount.
Infection remains the leading cause of death in patients with multiple myeloma. Several factors account for this infection risk, including the overall state of immunosuppression from multiple myeloma, treatment, age, and comorbidities (e.g., renal failure and frailty).
IMWG Consensus guidelines and recommendations for infection prevention in multiple myeloma; Lancet Haematol.2022;9(2):143–161.
Infection Prevention Tips
Good personal hygiene (skin, oral)
Environmental control (avoid crowds and sick people; use a high-quality mask when close contact is unavoidable)
Report fever of more than 100.4°F, shaking chills even without fever, dizziness, shortness of breath, low blood pressure to HCP as directed.
As recommended by your healthcare team:
Immunizations:
Flu, COVID, RSV & and pneumococcal vaccinations; avoid live vaccines
Preventative and/or supportive medications (next slide)
Medications Can Reduce Infection
Risk
Type of Infection Risk
Viral: Herpes Simplex (HSV/VZV); CMV
Bacterial: blood, pneumonia, and urinary tract infection
PJP (P. jirovecii pneumonia)
Fungal infections
COVID-19 and Influenza
Medication Recommendation(s) for Healthcare Team
Consideration
Acyclovir prophylaxis
Consider prophylaxis with levofloxacin
Consider prophylaxis with trimethoprimsulfamethoxazole
Consider prophylaxis with fluconazole
Antiviral therapy if exposed or positive for covid per institution recommendations
IgG < 400 mg/dL (general infection risk) IVIg recommended
ANC < 1000 cells/μL (general infection risk)
Consider GCSF 2 or 3 times/wk (or as frequently as needed) to maintain ANC > 1000 cells/μL and maintain treatment dose intensity
Some people receiving BCMA-targeting therapies have experienced infections that are less common like CMV, PJP and fungal infections
Management of Oral Side Effects
Dry Mouth
OTC dry mouth rinse, gel, spray are recommended. Advise patients to avoid hot beverages. Initiate anti-fungal therapy for oral thrush
Dexamethasone oral solutions “swish and spit” have been tried but with no proven benefit yet. Sour citrus or candies before meals are also recommended. Taste Changes
Dietary modifications with small bites, eating upright, and sips with food can help manage symptoms.
Some medications lead to weight gain, others to weight loss. Dry mouth leads to taste changes which can lead to anorexia.
Meet with a Nutritionist
Consider diet changes, supplements Monitor
Dysphagia
Catamero D, Purcell K, Ray C, et al. Presented at
GI Symptoms: Prevention & Management
Fluid intake can help with both diarrhea and constipation and helps kidney function
Diarrhea may be caused by medications and supplements
• Laxatives, antacids with magnesium
• Antibiotics, antidepressants, other (check with provider, pharmacist)
• Supplements: milk thistle, aloe, cayenne, saw palmetto, ginseng
Avoid caffeinated, carbonated, or heavily sugared beverages
Take anti-diarrheal medication if recommended and no cause related to infection
Constipation may be caused by medications and supplements
• Opioid pain relievers, antidepressants, heart or blood pressure medications (check with provider, pharmacist)
• Supplements: Calcium, Iron, vitamin D (rarely), vitamin B-12 deficiency
Increase fiber
• Fruits, vegetables, high fiber whole grain foods
• Fiber binding agents – Metamucil®, Citrucel®, Benefiber®
Discuss GI issues with healthcare providers to identify causes and make adjustments to medications and supplements
Skin and Nail Side Effects
Possible side effect to some treatments and supportive care medications
Skin Rash:
• Prevent dry skin; apply lotion
• Report changes to your care team
• Medication interruption or alternative, as needed
• Steroids:
• Topical for grades 1-2,
• Systemic and topical for Grade 3
Nail Changes:
• Antihistamines, as needed
• Keep your nails short and clean. Watch for “catching and tearing”
• Apply a heavy moisturizer like Vaseline or salve. Wear cotton hand coverings to bed
• A nail hardener may help with thinning
• Tell the team if you have signs of a fungal infection, like thickened or discolored nails
Photos: Mount Sinai Hospital, NY, NY
Feel Like a Spring Chicken: Prevent and Manage Pain
Pain can significantly compromise quality of life
Sources of pain include bone disease, neuropathy and medical procedures
• Management
• Prevent pain when possible
• Bone strengtheners to decrease fracture risk
• Antiviral to prevent shingles
• Sedation before procedures
• Interventions depend on source of pain
• May include medications, activity, surgical intervention, radiation therapy, etc
• Complementary therapies (Mind-body, medication, yoga, supplements, acupuncture, etc)
• Scrambler therapy for neuropathy
Tell your healthcare provider about any new bone or chronic pain that is not adequately controlled
Peripheral Neuropathy Management
Peripheral neuropathy happens when there is damage to nerves in the extremities (hands, feet, limbs). Damage can be the result of myeloma, treatment or unrelated conditions (i.e. diabetes).
Symptoms:
• Numbness
• Tingling
• Prickling sensations
• Sensitivity to touch
• Burning and/or cold sensation
• Muscle weakness
Prevention / management:
• Bortezomib once-weekly and/or subcutaneous administration
• Massage area with cocoa butter regularly
• Neuroprotective Supplements:
• B-complex vitamins (B1, B6, B12)
• Green tea
• Safe environment: rugs, furnishings, shoes
If neuropathy worsens, your provider may:
• Adjust your treatment plan
• Prescribe oral or topical pain medication
• Suggest physical therapy
Report symptoms of peripheral neuropathy early to your healthcare provider; nerve damage from neuropathy can be permanent if unaddressed
B, et al. CJON. 2017;21(5)suppl:19-36. Tariman, et al. CJON.2008;12(3)suppl:29-36. Zhao T, et al. Molecules. 2022;27(12):3909.
Understanding Changes to Kidney Function
• Risk Factors
• Active multiple myeloma (light chains, high calcium)
• Other medical issues (ex: Diabetes, dehydration, infection)
• Medications (MM treatment, antibiotics, contrast dye)
• Poor Nutrition
• Prevention
• Stay hydrated – drink water
• Avoid certain medications when possible (eg, NSAIDs), dose adjust as needed
• Treatment
• Treatment for myeloma
• Hydration
• Dialysis
Many myeloma patients will experience kidney issues at some point; protecting your kidney function early and over time is important
Additional Supportive Care
Supportive Medications
Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Dimopoulous M, et al. Leukemia. 2009;23(9):1545-56. Brigle K, et al. CJON. 2017;21(5)suppl:60-76. Faiman B, et al. CJON. 2017;21(5)suppl:19-36.
Faiman B, et al. CJON. 2011;15suppl:66-76. Miceli TS, et al. CJON. 2011;15(4)suppl:9-23.
Summer of Success
Let the Sun Shine In
Fatigue is the most reported symptom. Sources include anemia, pain, reduced activity, insomnia, treatment toxicity, bone marrow suppression 98.8%
Often, people do not share these symptoms with their providers. Talk to your provider about symptoms that are not well controlled or if you have thoughts of self-harm.
>35% of patients
of patients
Care Partners Are Vital for Success
If you want to go fast, go alone, if you want to go far, go together
• Care partners may help with medical appointments, managing medication, daily living, physical assistance, emotional support, myeloma knowledge, healthy lifestyle, patient advocacy, financial decisions
• Care partners can be a spouse, close relative, a network of people (family, friends, church members, etc)
African Proverb
• Caring for the Care Partner
• Recognize that caregiving is difficult/stressful
• Encourage care partners to maintain their health, interests, and friendships
• The IMF has information and resources to help care partners
Cultivate A Care Network
• Multiple studies demonstrate that strong social ties are associated with
• Increased longevity including people with cancer
• Improved adherence to medical treatment leading to improved health outcomes
• Lower risk of cardiovascular diseases
• Increased sense of purpose & life satisfaction
• Improved mood and happiness
• Reduced stress and anxiety
• Enhanced resilience
Martino J, et al. Am J of Lifestyle Med. 2015;11(6):466-475. Yang YC, et al. Proc Natl Acad Sci U S A. 2016;113(3):578-583. Pinquart M and Duberstein PR. Crit Rev Oncol Hematol. 2010; 75(2):122–137.
• Strategies for enhancing social connection
• Deepen existing relationships with family, friends, and loved ones
• Build new relationships by participating in a support group, joining clubs or organizations, or volunteering
Tip: Start with small steps outside your comfort zone. Call a loved one you haven’t spoken to in a while. Invite a person you’d like to know better for lunch, coffee, or a walk.
Hetherington C. Healthnews.
https://healthnews.com/longevity/healthspan/social-connection-andlongevity/#:~:text=Research%20consistently%20demonstrates %20that%20people,of%20fulfillment%20in%20your%20life. Accessed Feb 1 2024.
Enjoy Life’s Bounty
Harvest Good Health
Have a Primary Care
Provider & Have Recommended Health Screenings
• Blood pressure
• Cholesterol
• Cardiovascular disease
• Diabetes
• Colonoscopy
• Women specific: mammography, pap smear
• Men specific: prostate
• Vision
• Hearing
• Dermatologic evaluation
• Dental checkups & cleaning
Develop & maintain healthy behaviors
• Good nutrition
• Regular activity
• Quit tobacco use
• Sufficient Sleep (next slide)
Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Dimopoulous M, et al. Leukemia. 2009;23(9):1545-56.
An ounce of prevention is worth a pound of cure. Benjamin Franklin
Brigle K, et al. CJON. 2017;21(5)suppl:60-76. Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Faiman B, et al. CJON. 2011;15suppl:66-76. Miceli TS, et al. CJON. 2011;15(4)suppl:9-23.
Plentiful Sleep: Important for Good Health
• Adequate rest and sleep are essential to a healthful lifestyle
• Shortened and disturbed sleep cause
• Increased heart-related death
• Increased anxiety
• Weakened immune system
• Worsened pain
• Increased falls and personal injury
• Things that can interfere with sleep
• Medications: steroids, stimulants, herbal supplements
• Psychologic: fear, anxiety, stress
• Physiologic: sleep apnea, heart issues, pain
• Sleep hygiene is necessary for quality nighttime sleep and daytime alertness
• Engage in exercise but not too near bedtime
• Increase daytime natural light exposure
• Avoid daytime napping
• Establish a bedtime routine - warm bath, cup of warm milk or tea
• Associate your bed ONLY with sleep
• Avoid before bedtime:
• Caffeine, nicotine, alcohol and sugar
• Large meals and especially spicy, greasy foods
• Computer screen time
• Sleep aid may be needed
Rod NH et al 2014. PloS one. 9(4):e91965; Coleman et al. 2011. Cancer Nurs. 34(3):219-227.National Sleep Foundation. At: http://sleepfoundation.org/ask-the-expert/sleep-hygiene
Mustian et al. Journal of clinical Oncology. Sep 10 2013;31(26):3233-3241; Stan DL, et al. Clin J Oncol Nurs. Apr 2012;16(2):131-141; Zeng Y et al., Complementary therapies in medicine. Feb 2014;22(1):173-186.
