Is multiple myeloma painful?

Is Multiple Myeloma Painful?

Yes, multiple myeloma is commonly associated with significant pain, particularly bone pain, which affects approximately 80% of patients due to osteolytic lesions and vertebral compression fractures. 1

Causes of Pain in Multiple Myeloma

Multiple myeloma causes pain through several mechanisms:

1. Bone Destruction

   • Osteolytic lesions (bone destruction) are present in up to 80% of patients at diagnosis 1
   • These lesions weaken bones and lead to skeletal-related events (SREs)
   • Pain occurs due to:
     • Bone destruction from increased osteoclastic activity
     • Decreased osteoblastic function (reduced bone formation)

2. Vertebral Compression Fractures

   • Almost 80% of patients with vertebral compression fractures experience pain that is often non-responsive to standard pain medications 1
   • These fractures can cause severe, debilitating pain and mobility issues

3. Pathological Fractures

   • Long bone fractures cause acute, severe pain
   • Require surgical intervention for stabilization

4. Spinal Cord Compression

   • Extremely painful and can lead to neurological deficits
   • Considered a medical emergency

Management of Pain in Multiple Myeloma

Anti-Myeloma Therapy

Treating the underlying disease is fundamental to pain management, as effective control of myeloma can reduce bone destruction.

Bone-Targeted Therapies

1. Bisphosphonates (BPs)

   • First-line treatment for bone disease in myeloma 1
   • Zoledronic acid or pamidronate should be given to patients with adequate renal function and bone disease 1
   • Dosing considerations:
     • For patients with CrCl 30-60 mL/min: reduced doses of zoledronic acid or pamidronate via 4-hour infusion 1
     • Avoid in patients with CrCl <30 mL/min 1

2. Denosumab

   • Alternative for patients with renal impairment
   • Currently indicated for resistant hypercalcemia to BPs 1

Interventional Approaches

1. Radiotherapy

   • Indicated for extremely painful lytic lesions 1
   • Typical dose: 3000 cGy in 10-15 fractions 1
   • Provides effective pain relief but may delay systemic anti-myeloma therapies

2. Balloon Kyphoplasty/Vertebroplasty

   • Treatment of choice for painful vertebral compression fractures 1
   • Nearly 80% of patients experience pain relief when conventional pain management fails 1
   • Kyphoplasty is preferred due to lower rates of cement leakage (Grade 1A evidence) 1

3. Surgery

   • Indicated for:
     • Fixing pathological fractures of long bones
     • Stabilizing unstable spinal fractures
     • Spinal cord compression with bone fragments 1

Pain Management Algorithm

For pain control, a stepwise approach is recommended:

1. Mild Pain

   • Paracetamol/acetaminophen (up to 1g four times daily) 1
   • Avoid NSAIDs due to potential renal complications (Grade 2C) 1

2. Moderate Pain

   • Oral tramadol or codeine 1
   • Consider adjuvant medications

3. Severe Chronic Pain

   • Fentanyl or buprenorphine patches
   • Oxycodone 1
   • Always provide laxatives with opioids (Grade 1A) 1

4. Acute Severe Pain

   • Subcutaneous opioid injections (oxycodone or morphine) for rapid relief 1

5. Adjuvant Medications

   • Calcium channel blockers (gabapentin, pregabalin)
   • Sodium channel blockers (lidocaine, oxcarbazepine)
   • Serotonin-norepinephrine reuptake inhibitors (duloxetine, amitriptyline) 1

Common Pitfalls and Caveats

1. Renal Function Monitoring

   • Essential when using bisphosphonates
   • Measure CrCl before each infusion 1
   • Discontinue if renal function deteriorates until CrCl returns to within 10% of baseline 1

2. Dental Health

   • Thorough dental examination before bisphosphonate therapy
   • Resolve major dental problems before starting treatment 1
   • Risk of osteonecrosis of the jaw with bisphosphonates 2

3. Pain Assessment

   • Regular assessment of pain intensity and character is crucial
   • Differentiate between nociceptive and neuropathic pain components
   • Consider treatment-related pain (e.g., chemotherapy-induced peripheral neuropathy)

4. Balancing Pain Control and Side Effects

   • Monitor for opioid-related adverse effects
   • Some patients may experience severe bone pain after bisphosphonate infusion 2

Multiple myeloma pain management requires a comprehensive approach that addresses both the underlying disease and provides symptomatic relief. Early intervention with appropriate bone-targeted therapies and analgesics can significantly improve quality of life for patients with this painful condition.