From the Guidelines
Anemia in Multiple Myeloma (MM) is primarily managed with erythropoiesis-stimulating agents (ESAs) and red blood cell transfusions.
Management Options
- Erythropoiesis-stimulating agents (ESAs): such as erythropoietin (Epo)-a and β as well as darbepoetin, can increase hemoglobin (Hb) levels by 2 g/dL or more in 60% to 75% of myeloma patients with symptomatic anemia 1.
- Red blood cell transfusions: are helpful for patients who need rapid improvement of their anemic condition 1.
- Iron supplementation: is essential in cases of iron deficiency, which is indicated by low transferrin saturation, and can improve response to ESAs 1.
Guidelines
The American Society of Hematology (ASH) and American Society of Clinical Oncology (ASCO) recommend the administration of ESAs at the lowest possible dose to avoid transfusions 1. The European Myeloma Network (EMN) guidelines emphasize the importance of prophylaxis and supportive treatment for anemia in myeloma patients 1. Additionally, the ESMO clinical practice guidelines provide recommendations for managing anemia in patients with cancer, including those with MM 1.
Key Considerations
- Predictors of response to ESAs: include the ratio of observed to expected Hb (<0.9) and the preserved BM function, reflected by the platelet counts 1.
- Dose and administration: ESAs should be administered at the lowest possible dose to avoid transfusions 1.
From the Research
Management Options for Anemia in Multiple Myeloma (MM)
- Anemia is a common complication in patients with multiple myeloma (MM), occurring in more than two thirds of all patients 2.
- The most frequent underlying pathophysiological mechanisms include anemia of chronic disease, relative erythropoietin (EPO) deficiency, and myelosuppressive effects of chemotherapy 2, 3, 4.
Treatment Options
- Red blood cell (RBC) transfusions can provide an immediate effect and rapidly increase the patient's hemoglobin level, but the effects are only transient and can be associated with several risks, including infections and mild to life-threatening immunologic reactions 2, 5.
- Recombinant human erythropoietin (rHuEPO) is a biologically equivalent to the human endogenous hormone EPO, and its application leads to an increase of hemoglobin levels over an extended time without the risks of blood transfusions 2, 6, 5.
- Erythropoiesis-stimulating agents (ESAs) have been the standard of care since the early 90's, offering high response rates and improving the quality of life of patients, but their role in the treatment of cancer-related anemia has been questioned recently due to the growing evidence of increased risk for thrombosis and detrimental impact on patients' survival 3.
Recommendations for Epoetin Treatment
- An international expert panel recommended the use of rHuEPO for anemic myeloma patients where other possible causes of anemia have been eliminated 2.
- Epoetin should be administered to any patient with hemoglobin < or = 10 g/dl, and patients with hemoglobin 10-12 g/dl should receive epoetin if they suffer from significant symptoms of anemia and/or have progressively decreasing hemoglobin values 5.
- Dosage should be initiated at 10,000 IU three times/week or 40,000 IU once/week and be titrated to maintain hemoglobin at 12 g/dl 5.