What is the management for an 82-year-old female with a recent diagnosis of multiple myeloma and a lumbar compression fracture, presenting with poor appetite and hypercalcemia?

From the Guidelines

Management of this 82-year-old female with multiple myeloma, lumbar compression fracture, and poor appetite should prioritize a multifaceted approach focusing on pain control, appropriate chemotherapy, orthopedic consultation for the compression fracture, and nutritional support. Given her poor performance status, as indicated by poor appetite, a 2-drug regimen for multiple myeloma can be considered initially, with the possibility of adding a third drug if her performance status improves, as suggested by the NCCN guidelines 1. Pain control is crucial and can be achieved with analgesics such as acetaminophen, NSAIDs if not contraindicated, or opioids for severe pain. For the multiple myeloma, consultation with oncology is essential to determine the appropriate chemotherapy regimen, which may include combinations of bortezomib, lenalidomide, and dexamethasone, adjusted for her age and functional status. The compression fracture may require orthopedic consultation for possible vertebroplasty or kyphoplasty to stabilize the vertebra and reduce pain. Key considerations in managing her multiple myeloma include:

• The use of subcutaneous administration of bortezomib, which is preferred due to reduced peripheral neuropathy compared to intravenous administration, as demonstrated in the MMY-3021 trial 1.
• Careful assessment and monitoring for cardiac, renal, and pulmonary toxicities if carfilzomib is considered 1.
• The option for daratumumab intravenous infusion or daratumumab and hyaluronidase-fihj subcutaneous injection, with consideration of the patient's suitability for subcutaneous treatment 1. For poor appetite, nutritional support is crucial, including dietary consultation, high-calorie supplements, and possibly appetite stimulants like megestrol acetate (400-800 mg daily) or dexamethasone (2-4 mg daily) if not part of her myeloma regimen. Addressing underlying causes of poor appetite such as pain, medication side effects, depression, or constipation is important. Regular monitoring of renal function, calcium levels, and complete blood counts is necessary as myeloma can cause hypercalcemia and renal impairment. Physical therapy should be initiated for safe mobilization and to prevent further bone complications. This comprehensive approach addresses both the underlying malignancy and its complications while supporting the patient's nutritional status and quality of life, in line with guidelines for managing multiple myeloma-related complications 1.

From the FDA Drug Label

Table 9: Most Commonly Reported (≥ 10% Overall) Adverse Reactions in Integrated Analyses of Relapsed Multiple Myeloma and Relapsed Mantle Cell Lymphoma Studies The management of an 82-year-old female with recent diagnosis of multiple myeloma and lumbar compression fracture, and poor appetite, is not directly addressed in the provided drug labels.

• Key considerations:
  • The patient's poor appetite may be related to the underlying disease or to potential adverse reactions of the treatment.
  • Bortezomib is associated with several adverse reactions, including nausea, diarrhea, asthenic conditions, peripheral neuropathies, and thrombocytopenia.
• Clinical decision:
  • The patient's management should be individualized, taking into account her overall health status, the severity of her multiple myeloma, and the potential risks and benefits of treatment with bortezomib.
  • Close monitoring of the patient's appetite, nutritional status, and overall condition is necessary to ensure optimal management.
  • Consideration of alternative treatments or supportive care measures may be necessary to address the patient's poor appetite and other symptoms. 2 2

From the Research

Management of Multiple Myeloma

• The management of multiple myeloma involves the use of various therapies, including lenalidomide and dexamethasone 3, 4, 5, 6.
• Lenalidomide and dexamethasone (LenDex) is an active regimen for relapsed/refractory multiple myeloma (MM) 3.
• The combination of lenalidomide, bortezomib, and dexamethasone has also been shown to be effective in the treatment of newly diagnosed multiple myeloma 5.

Treatment Considerations

• The dosing of lenalidomide should be adjusted according to renal function to minimize toxicity 3.
• Patients with renal impairment may still be treated with LenDex without excessive toxicity 3.
• The risk of neutropenia may be higher in patients with low hemoglobin levels (7).

Specific Considerations for the Patient

• For an 82-year-old female patient with a recent diagnosis of multiple myeloma and lumbar compression fracture, poor appetite, and potentially impaired renal function, the treatment regimen should be carefully selected and monitored 3, 4, 5, 6.
• The patient's age, renal function, and overall health status should be taken into account when determining the appropriate treatment regimen 3, 4, 5, 6.