Treatment of COVID-19 in Multiple Myeloma Patients
Patients with multiple myeloma who develop COVID-19 with fever should receive antiviral treatment due to their high-risk immunocompromised status, even if not currently on myeloma treatment. 1, 2
Risk Assessment for Multiple Myeloma Patients with COVID-19
Multiple myeloma patients are at increased risk for severe COVID-19 complications due to:
- Immunocompromised state from the disease itself
- Older age (median 69 years in hospitalized MM patients) 3
- Common comorbidities (renal disease, cardiovascular disease)
- Higher mortality rates (33% among hospitalized MM patients) 3
Independent predictors of adverse outcomes in MM patients with COVID-19 include:
- Advanced age
- High-risk myeloma
- Renal disease
- Suboptimal myeloma control (active/progressive disease) 3
Treatment Recommendations
First-line Antiviral Treatment:
- Nirmatrelvir/ritonavir (Paxlovid) is recommended as first-line therapy for MM patients with COVID-19 and fever 4
- Dosage: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir twice daily for 5 days
- Must be started within 5 days of symptom onset
- Adjust dosing for renal impairment:
- Moderate impairment (eGFR 30-60 mL/min): 150 mg nirmatrelvir with 100 mg ritonavir twice daily
- Severe impairment (eGFR <30 mL/min): 300 mg nirmatrelvir with 100 mg ritonavir on day 1, then 150 mg nirmatrelvir with 100 mg ritonavir once daily for days 2-5
Important Considerations:
Drug interactions: Carefully review all medications as ritonavir is a strong CYP3A inhibitor 5
- Consider temporarily pausing interacting medications during the 5-day treatment course
- Common MM treatments may have significant interactions with ritonavir
Alternative options if Paxlovid is contraindicated:
Management of Multiple Myeloma During COVID-19
- Temporarily interrupt anti-myeloma treatment until COVID-19 symptoms resolve 6
- For asymptomatic patients with positive SARS-CoV-2 PCR, consider 14-day quarantine if myeloma status allows treatment delay 6
- Resume myeloma treatment after clinical resolution and negative PCR test 1
Monitoring and Follow-up
- Monitor for clinical deterioration: temperature ≥38°C, increasing shortness of breath, tachypnea (>20 breaths/min), hypoxia 2
- Consider hospitalization for patients with:
- Oxygen saturation <90%
- Respiratory rate >30/min
- Signs of severe disease 1
Special Considerations
- Despite immunocompromised status, some MM patients can mount effective immune responses against SARS-CoV-2 7
- Consider immune response assessment to guide decisions about restarting anti-myeloma therapy 7
- Rare cases of MM remission following COVID-19 have been reported, though this should not influence treatment decisions 8
Prevention Strategies
- Patient education on personal hygiene and social distancing
- COVID-19 vaccination (following CDC or local health authority guidelines) 2
- PCR testing before hospital admission or starting new treatment lines 6
- Consider telemedicine for stable patients to minimize exposure risk 6
Remember that MM patients with COVID-19 require prompt antiviral treatment regardless of their current myeloma treatment status due to their inherently immunocompromised state and high risk for severe outcomes.