Multiple Myeloma and Anemia

At least 60%-70% of patients with multiple myeloma have anemia at the time they are diagnosed. Learn about symptoms and causes of anemia and how it is managed.

What Is Anemia?

Myeloma cells interfere with the blood-producing activities of bone marrow, often leading to anemia. Anemia is the shortage of red blood cells (RBC, erythrocytes). RBCs transport oxygen from the lungs to the organs
and tissues in the body. If the body does not receive enough oxygen, the results are

• exhaustion
• shortness of breath, and
• the inability to carry out the activities of daily living.

Myeloma often presents with anemia as the first symptom. Anemia is very common in myeloma patients. At least 60%–70% of patients have anemia at the time they are diagnosed with myeloma. Most patients with myeloma experience anemia at some point during their disease course. If your doctor suspects you have anemia, a physical examination will be performed and your blood will be drawn for lab tests. It is wise to bring a family member or caregiver with you to your appointment. He or she may be able to add to the information you provide. 

Be sure to report the following symptoms to your physician:

• shortness of breath
• lack of energy and motivation
• rapid heartbeat
• swelling of the legs, especially the ankles
• dizziness
• headache
• chills
• change in appetite
• decreased libido

How Is Anemia Detected?

• Hemoglobin level, determined through a simple blood test, measures the number of red blood cells (RBCs) in the body.
  • Low hemoglobin levels indicate anemia, with normal ranges from 14 to 18 g/dL for men and 12 to 16 g/dL for women.
  • A hemoglobin level 2 grams or more below the pre-diagnosis normal level signifies anemia in myeloma patients.

Causes of Anemia

Anemia may not only be caused by multiple myeloma, but may also be caused by the following:

These treatments are known to cause anemia in a significant number of patients:

• Revlimid®, alone or in combination
• Kyprolis®, alone or in combination
• Pomalyst®, alone or in combination
• Darzalex®, alone or in combination (although not as commonly as the above drugs)

Decreased Kidney Function

• May be the result of myeloma-related free light chain protein blocking the tubules of the kidneys
• May be a pre-existing condition not related to myeloma (for example, the result of diabetes)
• May result in reduced levels of erythropoietin, a hormone released by the kidneys that helps the bone marrow make red blood cells
• May be caused by medications such as:

1. antibiotics taken for a long time and/or at a high dose
2. bisphosphonates (Aredia® and Zometa®) for myeloma-related bone disease
3. NSAIDs (such as Advil®, Motrin®, Naprosyn®) for pain relief
4. some blood pressure medications (diuretics such as Lasix)
5. contrast media given for imaging studies (such as gadolinium used in MRIs)
6. proton pump inhibitors (such as Prilosec®, Prevacid®, Nexium®)
7. some supplements (such as creatine and wormwood oil)
8. laxatives and enemas containing sodium phosphate (such as FLEET® products and MiraLAX®)
9. some medications for diabetes or high cholesterol (discuss with your treating doctor)

Poor Nutrition

• Iron, vitamin B12, and folic acid (folate) are required to produce hemoglobin
• Poor dietary intake is an important cause of low folate and low vitamin B12 levels

Active Bleeding

• Active bleeding that may be the result of hemorrhoids or a low platelet level (thrombocytopenia). Platelets are blood cells that help clot the blood.
• Thrombocytopenia can also be a side effect of treatments for myeloma, including the proteasome inhibitors Velcade®, Kyprolis, and Ninlaro®, and the immunomodulatory drugs Revlimid and Pomalyst.

How Is Anemia Treated?

• Treating myeloma is prioritized for newly diagnosed patients with anemia, as successful treatment often restores normal RBC production.
• Therapy response ideally leads to normalized blood counts, though treatment side effects may cause drops in blood cell counts.
• Certain myeloma treatments can suppress bone marrow's ability to produce blood cells, leading to anemia.
• Blood transfusions are recommended for the immediate correction of anemia, but the increase in hemoglobin levels may be modest and temporary, necessitating repeated transfusions.
• Prolonged transfusion can lead to resistance to transfused blood from other donors

Managing Anemia and Its Related Fatigue Due to Myeloma Treatment

• As discussed, myeloma treatments can lower all blood cell counts, including red blood cells (RBCs), leading to anemia.
• If treatment-induced anemia occurs while myeloma is improving, doctors may recommend a blood transfusion and/or an erythropoiesis stimulating agent (ESA).
  • ESAs like epoetin alfa or pegfilgrastim stimulate RBC production when used alongside chemotherapy.
  • ESAs have their own side effects and risks, including potential association with increased tumor growth and reduced survival in some cancer patients.
  • Caution should be exercised when considering ESAs, balancing potential benefits against risks.