Can Multiple Myeloma Cause Bleeding?
Yes, multiple myeloma (MM) can cause bleeding through several mechanisms, primarily through coagulation abnormalities, thrombocytopenia, and acquired hemostatic defects. 1
Mechanisms of Bleeding in Multiple Myeloma
Coagulation Abnormalities
- Thrombin inhibition: MM can produce substances that inhibit thrombin activity, preventing normal fibrin formation and leading to bleeding complications 1
- Acquired coagulopathy: Paraproteins can interfere with normal clotting factor function and platelet aggregation
Hematologic Factors
- Thrombocytopenia: Bone marrow infiltration by myeloma cells can reduce platelet production
- Platelet dysfunction: Paraproteins can coat platelets and impair their function even when counts are normal
Other Contributing Factors
- Hyperviscosity syndrome: High levels of paraproteins can lead to hyperviscosity, which paradoxically can cause both thrombotic and bleeding complications
- Renal dysfunction: Common in MM patients, can worsen uremic bleeding tendencies
- Treatment-related effects: Certain anti-myeloma therapies may contribute to bleeding risk
Clinical Presentation of Bleeding in MM
Bleeding manifestations in MM patients may include:
- Mucosal bleeding (epistaxis, gingival bleeding)
- Gastrointestinal bleeding
- Skin manifestations (petechiae, purpura)
- Intracranial hemorrhage (rare but serious)
Management Considerations
Assessment
- Evaluate coagulation parameters (PT, aPTT, fibrinogen, thrombin time)
- Check platelet count and function
- Consider specialized testing for paraprotein interference with coagulation
Treatment
- Primary treatment: Effective anti-myeloma therapy is the cornerstone of managing bleeding complications 1
- Supportive care: May include platelet transfusions, fresh frozen plasma, or cryoprecipitate depending on the specific coagulation abnormality
- Careful anticoagulation: While MM patients are at high risk for thromboembolism, anticoagulation must be carefully managed in those with bleeding tendencies
Thrombotic Risk vs. Bleeding Risk
It's important to note that MM is more commonly associated with an increased risk of thrombosis rather than bleeding:
- MM patients have a high baseline risk of venous thromboembolism (VTE) 2
- This risk is further increased with immunomodulatory drugs (IMiDs) like thalidomide and lenalidomide 2
- Thromboprophylaxis is recommended for MM patients on IMiD therapy 2
Recent evidence suggests that appropriate thromboprophylaxis in MM patients does not significantly increase bleeding risk. A MarketScan analysis found that anticoagulant prophylaxis did not result in increased bleeding risk in MM patients 3.
Conclusion
While MM is more commonly associated with thrombotic complications, bleeding can occur in approximately 7% of newly diagnosed MM patients 1. The primary management approach for MM-related bleeding is effective anti-myeloma therapy to address the underlying disease process. Clinicians should be vigilant about both thrombotic and bleeding risks in MM patients, with appropriate prophylaxis and monitoring based on individual risk factors.