How should I manage a patient with multiple myeloma who is COVID-19 positive with symptoms of cough and fever?

Management of COVID-19 in Multiple Myeloma Patients

For a multiple myeloma patient with COVID-19 presenting with cough and fever, treatment is strongly recommended with appropriate antiviral therapy, while temporarily discontinuing myeloma-directed therapy until clinical resolution of COVID-19 symptoms. 1

Initial Assessment and Management

• Diagnosis confirmation: Perform PCR test on nasopharyngeal swab to confirm SARS-CoV-2 infection 1
• Severity assessment: Evaluate for:
  • Oxygen requirements
  • Respiratory rate
  • Signs of lower respiratory tract disease
  • Need for hospitalization based on symptoms severity

Treatment Algorithm

1. Antiviral Therapy

• First-line treatment: Nirmatrelvir/ritonavir (Paxlovid) for mild-to-moderate COVID-19 presenting within 5-7 days of symptom onset 2

  • Important: Review for drug interactions with myeloma treatments before prescribing

• Alternative treatment: Intravenous remdesivir (VEKLURY) 3

  • Loading dose: 200 mg IV on day 1
  • Maintenance dose: 100 mg IV daily from day 2
  • Duration: 3 days for non-hospitalized patients; 5 days for hospitalized patients not requiring mechanical ventilation; 10 days for patients requiring mechanical ventilation 3

2. Myeloma Treatment Considerations

• Temporarily discontinue myeloma-directed therapy until clinical resolution of COVID-19 symptoms and viral clearance 1

  • Exception: JAK2-inhibitors, TKI/BTKi should be continued even during COVID-19 infection 1

• For asymptomatic SARS-CoV-2 positive patients: Consider 14-day quarantine if myeloma status allows treatment delay 4

3. Monitoring and Supportive Care

• Laboratory monitoring:

  • Hepatic function tests before and during remdesivir treatment 3
  • Prothrombin time before and during treatment 3
  • Complete blood count with differential to monitor for cytopenias

• Supportive care:

  • Fever management with antipyretics
  • Adequate hydration
  • Supplemental oxygen if needed

Special Considerations

High-Risk Features for Severe COVID-19 in Multiple Myeloma

Multiple myeloma patients are at higher risk for severe COVID-19 due to:

• Immunocompromised state from both disease and treatment 4
• Advanced age (median age 69 years in hospitalized MM patients with COVID-19) 5
• Comorbidities (particularly renal disease) 5
• Active or progressive myeloma 5
• ISS stage 3 disease 5

When to Resume Myeloma Treatment

• Ensure clinical and virological resolution of COVID-19 before resuming myeloma-directed therapy 1
• Obtain negative SARS-CoV-2 PCR test before restarting treatment, especially before cellular therapies like HSCT or CAR-T 1

Common Pitfalls and Caveats

1. Drug interactions: Nirmatrelvir/ritonavir has significant interactions with many myeloma treatments. Always check for interactions before prescribing 2

2. Delayed treatment: Do not postpone treatment for patients with myeloma emergencies, end-organ damage, or aggressive relapses despite COVID-19 infection 4

3. Prolonged viral shedding: Multiple myeloma patients may have prolonged viral shedding after COVID-19. Ensure viral clearance before resuming immunosuppressive therapies 1

4. Vaccination response: Multiple myeloma patients may have suboptimal response to COVID-19 vaccination. Consider this when assessing risk and management 2

5. Mortality risk: COVID-19 mortality in hospitalized multiple myeloma patients ranges from 27-57%, significantly higher than the general population 5

By following this structured approach, you can effectively manage COVID-19 in your multiple myeloma patient while minimizing complications and optimizing outcomes for both conditions.