What are the best treatments for Multiple Myeloma?

Multiple myeloma is a cancer of plasma cells, which are white blood cells responsible for producing antibodies. While not yet curable, advancements in therapy have transformed it into a manageable condition with treatments that can achieve long-term disease control and improved quality of life.

First-Line Treatment: Induction Therapy

Initial treatment typically involves induction therapy to rapidly reduce cancer cells. Common regimens include:

• VRd: Combines bortezomib (a proteasome inhibitor), lenalidomide (an immunomodulatory drug), and dexamethasone (a steroid).
• D-VTd or D-Rd: Adds daratumumab (an anti-CD38 monoclonal antibody) to triplet therapy, creating quadruplet regimens for deeper responses.

Transplant eligibility influences therapy choices. Patients eligible for autologous stem cell transplant (ASCT) often receive 3–4 cycles of induction first.

Role of Stem Cell Transplant

Stem cell transplant (SCT), also known as hematopoietic stem cell transplant, plays a significant role in the treatment of multiple myeloma, particularly for younger and healthier individuals. It's often used to allow for higher doses of chemotherapy, which can more effectively kill myeloma cells.

The primary reason for a stem cell transplant in multiple myeloma is to "rescue" the bone marrow from the damage caused by high-dose chemotherapy. While high-dose chemotherapy is very effective at killing myeloma cells, it also destroys the healthy blood-forming stem cells in the bone marrow. The transplant replenishes these stem cells, allowing the bone marrow to recover and produce new, healthy blood cells.

A stem cell transplant typically involves:

• Harvesting the patient’s stem cells.
• Administering high-dose chemotherapy to eliminate residual myeloma cells.
• Reinfusing stem cells to restore bone marrow function

Post-transplant maintenance therapy with lenalidomide prolongs remission and improves survival.

Relapsed/Refractory Treatment Options

Sometimes, myeloma does not respond to treatment (called refractory disease). Additionally, most patients with myeloma will experience relapse (return of cancer). Treatment for refractory or relapsed myeloma depends on many factors, but options include:

• Proteasome inhibitors: Carfilzomib (Kyprolis) or ixazomib (Ninlaro).
• Immunomodulatory drugs (IMiDs): Pomalidomide (Pomalyst).
• Monoclonal antibodies: Isatuximab (Sarclisa) or daratumumab (Darzalex).
• Nuclear export inhibitor: Selinexor (Xpovio)
• CAR T-cell therapies: Abecma (idecabtagene vicleucel) and Carvykti (ciltacabtagene autoleucel), which reprogram the immune system to target BCMA proteins on myeloma cells.
• Bispecific antibodies: Tecvayli (teclistamab) and Talvey (talquetamab), which engage T-cells to attack cancer.

Supportive Treatments and Symptom Management

For patients with multiple myeloma, treatment extends beyond targeting the cancer itself. Supportive treatments and symptom management strategies are an important part of comprehensive care.

Bone Health

Multiple myeloma can significantly impact bone health, leading to pain, weakness, and fractures. Several treatments are available to protect and strengthen bones:

• Bisphosphonates: These drugs, such as zoledronic acid (Zometa) and pamidronate (Aredia), are administered intravenously to slow bone breakdown, reduce bone pain, and lower the risk of fractures. They are a standard part of care for many myeloma patients.
• Denosumab (Xgeva): This is another option for preventing skeletal-related events. It works by blocking a protein involved in bone breakdown and is given as an injection under the skin.
• Radiation Therapy: Targeted radiation can be used to relieve pain and shrink tumors in specific areas of bone damage.
• Surgical Interventions: For fractures or vertebral compression, surgical procedures like vertebroplasty or kyphoplasty may be recommended. These involve injecting bone cement into the affected vertebrae to stabilize them and relieve pain.
• Pain Medication: A range of pain relievers, from over-the-counter options to stronger prescription medications, are used to manage bone pain.

Related questions

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Anemia and Fatigue

A common symptom of multiple myeloma is anemia, a deficiency of red blood cells, which leads to persistent fatigue and weakness. Management strategies include:

• Erythropoiesis-Stimulating Agents (ESAs): Medications like epoetin alfa (Procrit) or darbepoetin alfa (Aranesp) can stimulate the bone marrow to produce more red blood cells.
• Blood Transfusions: In cases of severe anemia, a blood transfusion can quickly increase red blood cell counts and alleviate symptoms.
• Iron and Vitamin Supplements: If the anemia is related to deficiencies in iron, vitamin B12, or folate, supplements may be prescribed.
• Managing Fatigue: Beyond treating anemia, managing fatigue involves balancing rest with gentle exercise, maintaining a healthy diet, and seeking support for the emotional and psychological aspects of living with a chronic illness.

Preventing and Managing Infections

Multiple myeloma and its treatments can weaken the immune system, making patients more susceptible to infections. There are several measures that can help reduce the risk of infection and related complications:

• Vaccinations: Staying up-to-date on vaccinations, including those for influenza, pneumonia, and COVID-19, is highly recommended.
• Intravenous Immunoglobulin (IVIG): For patients with low antibody levels and recurrent infections, infusions of IVIG can help bolster the immune system.
• Prophylactic Antibiotics and Antivirals: In some cases, preventative courses of antibiotics or antiviral medications may be prescribed, especially during certain phases of treatment.
• Good Hygiene: Simple practices like frequent handwashing and avoiding close contact with sick individuals can significantly reduce the risk of infection.

Summary and Clinical Considerations

Treatment plans for multiple myeloma are highly individualized, factoring in age, genetic risk, and comorbidities. Early referral to a hematologist/oncologist ensures access to cutting-edge therapies and clinical trials, which continue to redefine outcomes. With novel agents like bispecific antibodies and CAR T-cells, patients now have more options than ever to achieve durable remissions.

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