Standard dose Chemotherapy

People over 65 and people of working age who are ‘unfit’ are most likely to have this treatment.

The aim of treatment in this group is to get the disease into remission to reduce symptoms for as long as possible. It usually consists of oral chemotherapy drugs every 3-4 weeks taken over 6 to 8 months. During this phase of treatment, people attend the hospital clinic every month, although at times admission to the hospital may be needed if infection develops or if blood counts fall too low. Treatment may involve transfusion of blood products as a day case or inpatient. People are likely to be on one of the following treatment regimens:

The commonest treatment is melphalan and prednisolone with thalidomide. These drugs are given orally usually for six 4-week cycles. About half will respond to treatment and remain in remission for 18 to 24 months; during remission they will be well. Side effects of treatment include nausea which is usually mild, hair loss is unusual. Disabling effects include: sleepiness, constipation, increased risk of deep vein thrombosis. Peripheral nerve damage (numbness, tingling, altered sensation) may be caused by thalidomide if used over a prolonged period at high doses. In order to limit these problems, the dose is usually adjusted with each cycle to minimise these risks.

Cyclophosphamide with prednisolone or dexamethasone may be used instead of melphalan. It is usual to combine these combinations with thalidomide. Treatment is given once a week either intravenously or by mouth. See general notes for side effects of chemotherapy. Treatment is likely to last for 3-6 months.

Bortezomib and dexamethasone are now approved by the National Institute for Clinical Excellence (NICE) for use in patients who relapse after initial chemotherapy treatment. Bortezomib is administered by intravenous infusion twice a week for 2 weeks in a 3 week cycle, with dexamethasone given orally on the day of and the day after the bortezomib injection.

Disabling effects include:

• General side effects similar to thalidomide, except it may cause low platelets and bleeding disorders rather than thrombosis
• Patients may experience a change in their bowel habit- diarrhoea or constipation that may need additional medication to keep under control.
• An important side effect is peripheral nerve damage that may cause severe nerve pain, to the extent that strong pain killing medication is needed to counteract the effects. Peripheral nerve damage may affect motor function leading to difficulty using the hands or reduced mobility.
• Steroid side effects

Lenalidomide and dexamethasone. Lenalidomide is related to thalidomide. It is given orally once a day in a 21 day cycle with dexamethasone (also oral). Its side effects are different to thalidomide, although the 2 drugs are related.

Disabling effects include:

• Low blood counts, especially low white cell counts, putting them at risk of infection and low platelets causing a bleeding tendency.
• There is an increased risk of developing deep vein thrombosis. All patients need to take additional medication, such as aspirin to counteract this effect.

Other drugs used during and after first line chemotherapy.

Interferon

This may be used during primary chemotherapy, during chemotherapy for relapsed disease or as maintenance therapy in remission. It is given as a subcutaneous injection once a week. Flu like symptoms are common in the hours after injection and can be treated with paracetamol. Fatigue and depression are common side effects and these endure throughout the week between injections. Symptoms resolve when the drug is stopped. The drug is likely to be stopped if these side effects occur. This is a form of biological therapy – see general notes.

EPO

Erythropoietin is a drug given by injection which can increase red blood cell production. It can reduce the need for repeated blood transfusion and improve wellbeing in people with symptoms of anaemia.

Biphosphonates

Include clodronate, pamidronate and zoledronate. Clodronate is given orally; pamidronate and zoledronate are given as injections once a month.

These drugs reduce bone damage by myeloma and reduce the number of fractures, amount of bone pain and risk of hypercalcaemia. They do not prevent these problems entirely; 30-40% of people with myeloma will still experience vertebral fracture whilst on these drugs.

Thalidomide

May be used to maintain remission after chemotherapy treatment or in relapsed myeloma. Common side effects are tiredness, constipation and deep vein thrombosis (DVT), peripheral nerve damage (numbness, tingling, and altered sensation) may be caused by thalidomide if used over a prolonged period at high doses; this would be a reason to stop or reduce thalidomide and recovery is expected in the typical case.

Amended February 2009