NLB Resource - Managing Complications and Side Effects

The myeloma patient will require support to alleviate the physical and emotional impact of living with this illness. The IMF encourages early use of supportive care measures, which are just as important as initiating therapy. This section covers care guidelines for managing symptoms and side effects of myeloma. 

Overview of Palliative Care

Pain management should be ongoing. Other symptoms such as peripheral neuropathy, gastrointestinal issues, venous thromboembolic events, bone disease, and renal failure can arise as a result of the disease or therapy. Infections are a major cause of death in MM. Finally, many patients report fatigue and/or cognitive impairment. Throughout the course of the disease, the advanced practitioner can provide education, monitor symptoms, and supply supportive care measures. 

Medical Problems Related to Myeloma

Many of the drugs used to treat myeloma can cause myelosuppression, a decrease in bone marrow activity resulting in fewer red blood cells (anemia), white blood cells (neutropenia), and platelets (thrombocytopenia). The risk of myelosuppression varies with each medication. 

Learn more with this table:

Effects of Increased Myeloma Cells in Bone Marrow CRAB criteria	CAUSE	IMPACT on PATIENT
C - Increase in blood Calcium	Release of calcium from damanged bone in into the bloodstream	Mental confusion Dehydration Constipation Fatigue Weakness Renal or kidney damage
R - Renal problems - kidney damage	Abnormal monoclonal proteins produced by the myeloma cells are released into the bloodstream and can pass into the urine and produce kidney damage. High blood calcium, infections, and other factors can also cause or increase the severity of kidney damage.	Sluggish circulation Fatigue Mental confusion
A - Anemia	Decrease in number and activity of red blood cell-producing cells in the bone marrow.	Fatigue Weakness
B - Bone Damage Thinning (osteoporosis) or Areas of more severe damage (called lytic lesions), fracture, or collapse of a vertebra	The myeloma cells activate osteoclast cells, which destroy bone, and block osteoblast cells, which normally repair damaged bone.	Bone pain  Bone swelling Fracture or collapse of a bone Nerve or spinal cord damage
Additional types of organ dysfunction	Local or systemic effects of myeloma, other than CRAB features,	Neuropathy  Recurrent infections Bleeding problems Other individual problems
Abnormal immune function	The myeloma cellls reduce the number and activity of normal plasma cells capable of producing antibodies against infection.	Susceptibility to infections Delayed recovery from infection

Source: Durie. Patient Handbook. International Myeloma Foundation. 2017.

Many of the drugs used to treat myeloma can cause myelosuppression, a decrease in bone marrow activity resulting in fewer red blood cells (anemia), white blood cells (neutropenia), and platelets (thrombocytopenia). The risk of myelosuppression varies with each medication.

Patient risk factors	Disease-induced risk factors
Age > 65	Extensive disease
Low performance status (ECOG > 1)	Relapsed/refractory disease
Female	History of chemo or radiation
Immunosuppression	Pre-existing myelosuppression
Malnutrition	High plasmacytosis in bone marrow
Comorbidities	Elevated lactate dehydrogenase
Infections	Hypoalbuminemia
Wounds or recent surgery	Hyperbilirubinemia

See also this publication: Recommendations for Oncologic Emergencies: Myelosuppression, Bone Disease, and Acute Renal Failure (https://s3.us-west-1.wasabisys.com/imf-d8-prod/resource/MyelosuppressionBoneDisease_BrigleCJON2017.pdf).

Side Effects of Treatment

Corticosteroids

For many years, steroids have been an important and effective treatment for myeloma, used alone and in combination with other drugs. Steroids cause a wide range of side effects, affecting nearly every system of the body. Identifying the side effects early and managing them quickly will contribute to successful treatment and ultimately improve overall quality of life. Commonly prescribed steroids include dexamethasone, prednisone, prednisolone, and solumedrol.

Side Effects of Corticosteroids  (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-Side%20Effects%20of%20Corticosteroids.pdf)

Discussions about Continuing Treatment with Corticosteroid Side Effects (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Continuing%20Treatment%20after%20Corticosteroid%20Side%20Effects.pdf)

Bone Health Risk and Management

Most myeloma patients will develop osteolytic bone lesions. Thus, it is essential that supportive care target bone health. Maintenance of bone health also improves quality of life over the continuum of the disease.

Pain Management  (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Pain%20mgt%20for%20Providers%20Rome.pdf)

Diagnostic Imaging (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-10/New%20Imaging%20Table%209.30.pdf)

Risk Factors (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Miceli%20Bone%20Loss%20Risk%20Factors.pdf)

Drugs Associated with Increased Risk (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Miceli%20Drugs%20associated%20w%20risk%20of%20Fracture.pdf)

Reducing Risk (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON%20Miceli%20Factors%20to%20reduce%20Fracture.pdf)

Guidelines for Bisphosphonate Use  (https://www.myeloma.org/resource-library/imwg-guidelines-use-bisphosphonates-myeloma)

Long-Term Bone Health Plan Tool (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/7-CJON-Bone%20Health%20Survivor%20Plan%2C%20Miceli.pdf)

Renal, GI, and Neuropathy Symptoms

A renal care plan for myeloma patients in maintenance (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-faiman%20-%20renal%20-%20care%20plan%20for%20stable%20MM.pdf)

Practitioner’s guidelines for grading and managing peripheral neuropathy (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-Faiman%20-%20renal%20-%20grading%20neuropathy.pdf) 

Preventing and Watching for Venous Thromboembolism

Patients with myeloma may have an even higher risk for venous thromboembolic events (VTE) than other cancer patients. Therapies used to treat myeloma may increase the incidence of clots.

Risk factors for Venous Thromboembolism (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Noonan%20-%20VT%20Risk%20Factors.pdf)

VTE prevention (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Noonan%20-%20VT%20Prevention.pdf)

VTE signs and symptoms (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-%20Noonan%20Signs%20and%20Symptoms%20VT.pdf)

Preventing and Watching for Cardiovascular Disease

MM patients are at increased risk for cardiac events due to the disease and its treatments.

Risk factors for cardiovascular disease (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-Noonan%20-%20Cardio%20Risk%20Factors.pdf)

Therapies with cardio toxicity (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-Noonan%20-%20Therapies%20w%20cardio%20toxicity.pdf)

Prevention of cardiovascular disease (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-CJON-Noonan%20-%20Cardio%20Prevention.pdf)

NLB Publication: Heart and Lung Complications: Assessment and Prevention of VT and Cardiovascular Disease (https://s3.us-west-1.wasabisys.com/imf-d8-prod/resource/HeartLungComplications_Noonan_CJON2017.pdf)

Understanding and Treating Other Concerns 

Psychosocial care is critical to the emotional and physical well-being of the myeloma patient. Fatigue, depression, and anxiety, as well as concerns about sexual intimacy are common. The patient should be screened for these issues on a regular basis.

Anxiety and Depression
Nursing Recommendations for Addressing Anxiety and Distress (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-Catamero%20Nursing%20Recommendations%20for%20Distress.pdf)

Preventing and Managing Fatigue
Tip Sheet for Providers (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-catamero-Tip%20Sheet%20for%20Patients%20on%20Preventing%20and%20Managing%20Fatigue.pdf)
Fatigue Assessment Tool (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-catamero-Fatigue%20Assessment.pdf)

Discussing Sexual Intimacy Concerns
Discussing sexual dysfunction  (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-catamero%20Discussing%20Sexual%20Dysfunction.pdf)
Making a specialist referral for sexual dysfunction (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2019-07/5-cjon-catamero-Specialist%20Referral%20for%20Sexual%20Dysfunction.pdf)