What is the management approach for a myeloma patient with elevated albumin on serum protein electrophoresis (SPEP) who is currently on Revlimid (lenalidomide) or Velcade (bortezomib) therapy?

Management of Elevated Albumin on Serum Protein Electrophoresis in Myeloma Patients on Treatment

For myeloma patients on Revlimid (lenalidomide) or Velcade (bortezomib) therapy who show elevated albumin on serum protein electrophoresis (SPEP), continued monitoring with regular SPEP and immunofixation is recommended, as this finding alone does not indicate disease progression or treatment failure. 1, 2

Diagnostic Approach

• When elevated albumin is detected on SPEP in a treated myeloma patient, follow-up testing should include serum immunofixation electrophoresis (IFE) and serum free light chain assay to confirm the presence and identify any monoclonal protein 2
• Complete myeloma workup should be performed, including:
  • Quantitative immunoglobulins and quantitation of M protein (both serum and urine) 1
  • Complete blood count with differential and platelets 1
  • BUN, creatinine, calcium 1
  • Serum free light chain assay 1
  • Bone marrow aspirate and biopsy as clinically indicated 1

Interpretation of Elevated Albumin

• Elevated albumin on SPEP in a patient receiving myeloma therapy may represent:

  • A normal physiologic response to effective treatment (improved nutritional status) 1
  • Laboratory variation or artifact 2
  • Potential drug effect from lenalidomide or bortezomib 3

• This finding should be interpreted in the context of other disease markers, as albumin alone is not a reliable indicator of disease progression 1

Management Algorithm

1. Continue current therapy if other disease markers show response:

   • If M-protein is decreasing or stable 1
   • If bone marrow plasma cells are decreasing 1
   • If patient shows clinical improvement 1

2. Adjust monitoring frequency:

   • For patients on lenalidomide (Revlimid): Monitor SPEP, complete blood count, and renal function every 3-4 weeks 1
   • For patients on bortezomib (Velcade): Monitor SPEP and complete blood count every 3 weeks 4

3. Consider dose adjustments only if other concerning findings emerge:

   • For lenalidomide: Dose reduction may be needed if renal function deteriorates (CrCL 30-60 mL/min: reduce to 10 mg/day) 1
   • For bortezomib: Consider weekly administration instead of twice-weekly to reduce toxicity while maintaining efficacy 5

Response Assessment

• Response evaluation should be based primarily on:

  • Reduction in serum M-component (≥50% reduction for partial remission) 1
  • Reduction in 24-hour urine M-component (≥90% reduction for partial remission) 1
  • Bone marrow assessment (<5% plasma cells for complete remission) 1
  • Immunofixation results 1

• Albumin levels should be interpreted as part of the International Prognostic Index (IPI) rather than as a standalone marker of response 1

Special Considerations

• Liver function: Monitor for potential hepatotoxicity, especially with combination therapy, as some patients may experience elevated bilirubin during lenalidomide treatment 3

• Renal function: Closely monitor renal function in all patients under therapy, as it may affect drug dosing and clearance 1

• Drug interactions: Be aware that both lenalidomide and bortezomib can have complex interactions with other medications that may affect albumin metabolism 4

Follow-up Schedule

• Perform myeloma workup every 3-6 months during treatment 1
• Include serum chemistry for creatinine, albumin, calcium 1
• Conduct serum protein electrophoresis (SPEP) and serum immunofixation electrophoresis (SIFE) at each follow-up 1
• Consider bone marrow examination if there are other signs of disease progression 1

Common Pitfalls to Avoid

• Don't change therapy based on albumin elevation alone - this is not a validated marker of disease progression 1
• Don't overlook other markers of response - focus on M-protein levels, free light chain ratios, and bone marrow findings 1
• Don't confuse albumin elevation with M-protein spike - careful interpretation of SPEP is essential 2
• Don't miss potential drug-related effects - some medications can affect protein metabolism 3