Pain Management in Multiple Myeloma
For effective pain management in multiple myeloma patients, a stepwise approach based on pain severity is recommended, with paracetamol for mild pain, tramadol/codeine for moderate pain, and opioids for severe pain, while avoiding NSAIDs and always addressing the underlying bone disease with bisphosphonates. 1
Pain Assessment and Classification
Pain in multiple myeloma patients typically stems from:
- Bone disease (80% of patients) - osteolytic lesions and vertebral compression fractures 2
- Treatment-related pain (chemotherapy-induced peripheral neuropathy)
- Disease progression
Stepwise Pain Management Algorithm
Mild Pain
- Paracetamol up to 1g four times daily (grade 1B) 1
- Avoid NSAIDs in multiple myeloma patients (grade 2C) due to potential renal complications 1
Moderate Pain
- Oral tramadol or codeine (grade 1C) 1
- Consider adding adjuvant medications early
Severe Chronic Pain
- Fentanyl or buprenorphine patches or oral oxycodone (grade 1B) 1
- Always provide laxatives with opioids (grade 1A) to prevent constipation 1
Acute Severe Pain
- Subcutaneous opioid injections (oxycodone or morphine) for rapid relief (grade 2B) 1
Adjuvant Medications
All patients with chronic pain should be considered for:
- Calcium channel blockers (gabapentin, pregabalin)
- Sodium channel blockers (lidocaine, oxcarbazepine)
- Serotonin-norepinephrine reuptake inhibitors (duloxetine, amitriptyline) (grade 1B) 1
These medications are particularly helpful for neuropathic pain components, which are common in multiple myeloma.
Addressing Bone Disease
Bone disease treatment is crucial for comprehensive pain management:
- Bisphosphonates (zoledronic acid or pamidronate) should be given to patients with adequate renal function and bone disease 2
- Monitor renal function before each infusion 1
- For patients with renal impairment (CrCl 30-60 mL/min), consider reduced doses of zoledronic acid or pamidronate via 4-hour infusion 2
- Denosumab is an alternative for patients with significant renal impairment 2
Localized Pain Interventions
For focal painful lesions or vertebral compression fractures:
- Radiotherapy for extremely painful lytic lesions (3000 cGy in 10-15 fractions) 2
- Balloon kyphoplasty/vertebroplasty for painful vertebral compression fractures (kyphoplasty preferred due to lower cement leakage rates) 2
- Surgical intervention for pathological fractures of long bones, unstable spinal fractures, or spinal cord compression 2
Special Considerations
- Neuropathic pain is common in multiple myeloma patients, especially those receiving proteasome inhibitors like bortezomib 3
- Post-herpetic neuralgia may occur due to varicella zoster virus reactivation in immunocompromised patients 3
- Regular pain assessment is essential as pain patterns may change with disease progression 2
Monitoring
- Assess pain intensity and character regularly
- Monitor renal function when using bisphosphonates
- Evaluate for side effects of pain medications, particularly constipation with opioids
By following this structured approach to pain management in multiple myeloma, clinicians can significantly improve patients' quality of life while addressing the underlying disease processes that contribute to pain.