Hi everyone. New poster, but have been trawling these forums for a month or 2.
49 year old male, diagnosed Stage 2, IgG Kappa multiple myeloma with standard risk cytogenetics in Oct 2013. History of back pain and partially collapsed vertebra.
At diagnosis, Kappa 141, Lambda 6.17, ratio 22.85, M-spike 2.6, Gamma globulins 3.5, bone biopsy 26% plasma cells.
Started Velcade / cyclophosphamide / dexamethasone [VCD, CyBorD] in the usual 28 day cycles Nov 2013 (plus monthly Zometa injections for the bone to be taken for 24 months)
After cycle 1, Kappa 18.2, Lambda 6.12, ratio 2.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After cycle 3, Kappa 14.2, Lambda 13.7, ratio 1.04. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.77
After cycle 4, Kappa 14.2, Lambda 1.12, ratio 11.6. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After the encouraging results post end of the 3rd cycle (normal FLC ratio, etc), the plan was to do 1 more cycle and then do a bone marrow biopsy and then go on to a thalidomide maintenance programme and then take it from there.
But now the crazy low Lambda reading on my latest FLC test has thrown a spanner in the works. I have Kappa light chain multiple myeloma and it is heartening to see that the Kappa FLC reading (which is the 'involved' chain) remaining rock steady at 14.2. But the suppressed Lambda reading has thrown the ratio askew.
By way of info, I have decided to wait for first relapse before doing an auto SCT.
Questions - what is the significance of a suppressed Lamda, but normal Kappa, in a kappa multiple myeloma scenario. I read somewhere that a low reading - Lambda or Kappa - does not signify disease, but instead something else going on like marrow compression etc
My doctor has asked me to redo the test. But if the results are the same, how am I to interpret this? Do I still go onto the thalidomide maintenance programme originally planned?
How do I interpret the continuation of a 'weak band' in the Gamma region on the SPEP test ? Is it possible to have a M band even if one has light chain disease (and still have normal FLC ratios, as I did a month ago after completion of the 3rd cycle)?
Thanks a bunch in advance and I wish everyone the very best in their fight against this disease.
Regards /Robin
Forums
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi Robin,
Congrats on your progress so far.
A couple of things:
Your Question: Is it possible to have a M band even if one has light chain disease (and still have normal FLC ratios, as I did a month ago after completion of the 3rd cycle)?
Well, you really don't have "light chain disease", right? You started off with a fairly significant M-Spike, so clearly you aren't light chain restricted. It just sounds like you now have a nearly immeasurable M-Spike.
Note that chemo will tend to suppress the production of both immunoglobulins and free lite chains (both involved and uninvolved). It's not clear to me that the suppression of your uninvolved lambda free lite chain is something to really worry about and wouldn't necessarily reflect the presence of any monoclonal plasma cells (but a doctor really needs to confirm this).
It seems like the right thing to do is to get re-tested, and to evaluate everything including your bone marrow biopsy results after you complete the final chemo cycle. Your doc seems to be on top of things.
Congrats on your progress so far.
A couple of things:
Your Question: Is it possible to have a M band even if one has light chain disease (and still have normal FLC ratios, as I did a month ago after completion of the 3rd cycle)?
Well, you really don't have "light chain disease", right? You started off with a fairly significant M-Spike, so clearly you aren't light chain restricted. It just sounds like you now have a nearly immeasurable M-Spike.
Note that chemo will tend to suppress the production of both immunoglobulins and free lite chains (both involved and uninvolved). It's not clear to me that the suppression of your uninvolved lambda free lite chain is something to really worry about and wouldn't necessarily reflect the presence of any monoclonal plasma cells (but a doctor really needs to confirm this).
It seems like the right thing to do is to get re-tested, and to evaluate everything including your bone marrow biopsy results after you complete the final chemo cycle. Your doc seems to be on top of things.
-
Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi Multibily
Thanks very much for replying. So that I have this the right way around, is it the case that someone could have heavy chain and light chain disease simultaneously? In other words, an M-spike and also elevated kappa or lambda light chain values?
A further query - the SPEP usually records values for total protein, albumin, globulin, and then a breakup / electrophoresis of the globulin into it's constituents like alpha 1 globulin, alpha 2 globulin, beta globulin and gamma globulin.
My query is - If there an M-spike recorded on the SPEP, or, as in my case, a 'weak band' in the gamma region, which of these readings would be affected - i.e. would there be an increase in total protein, or an increase in just the gamma globulins, or something else.
I'm trying to make sense of my last SPEP which showed a week band in the gamma region but normal readings for all the albumin and globulin parameters.
Last question (sorry, just a but overwhelmed with the whole multiple myeloma thing at the moment) - what is the current thinking on use of thalidomide as maintenance? And dosage, frequency, duration etc.
Very thankful for any and all replies.
Regards
Robin
Thanks very much for replying. So that I have this the right way around, is it the case that someone could have heavy chain and light chain disease simultaneously? In other words, an M-spike and also elevated kappa or lambda light chain values?
A further query - the SPEP usually records values for total protein, albumin, globulin, and then a breakup / electrophoresis of the globulin into it's constituents like alpha 1 globulin, alpha 2 globulin, beta globulin and gamma globulin.
My query is - If there an M-spike recorded on the SPEP, or, as in my case, a 'weak band' in the gamma region, which of these readings would be affected - i.e. would there be an increase in total protein, or an increase in just the gamma globulins, or something else.
I'm trying to make sense of my last SPEP which showed a week band in the gamma region but normal readings for all the albumin and globulin parameters.
Last question (sorry, just a but overwhelmed with the whole multiple myeloma thing at the moment) - what is the current thinking on use of thalidomide as maintenance? And dosage, frequency, duration etc.
Very thankful for any and all replies.
Regards
Robin
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi Robin,
Regarding thalidomide maintenance therapy, here are some references that may be useful ...
"The role of maintenance thalidomide therapy in multiple myeloma: MRC Myeloma IX results and meta-analysis" (full text, pdf), Morgan et al, Blood, 2011
"Experts Publish Consensus Statement On Maintenance Therapy In Multiple Myeloma", Myeloma Beacon, 2012. For full details on thalidomide maintenance, see the complete consensus statement discussed in this article (full text, pdf).
"Strategies for induction, autologous hematopoietic stem cell transplantation, consolidation, and maintenance for transplantation-eligible multiple myeloma patients" (full text, pdf), McCarthy & Hahn, ASH Education Book, 2013
There also may be additional useful articles among those listed on the Beacon's maintenance therapy topic (tag) pages.
Regarding thalidomide maintenance therapy, here are some references that may be useful ...
"The role of maintenance thalidomide therapy in multiple myeloma: MRC Myeloma IX results and meta-analysis" (full text, pdf), Morgan et al, Blood, 2011
"Experts Publish Consensus Statement On Maintenance Therapy In Multiple Myeloma", Myeloma Beacon, 2012. For full details on thalidomide maintenance, see the complete consensus statement discussed in this article (full text, pdf).
"Strategies for induction, autologous hematopoietic stem cell transplantation, consolidation, and maintenance for transplantation-eligible multiple myeloma patients" (full text, pdf), McCarthy & Hahn, ASH Education Book, 2013
There also may be additional useful articles among those listed on the Beacon's maintenance therapy topic (tag) pages.
Re: Hi everyone - new member with IgG kappa multiple myeloma
Regarding: So that I have this the right way around, is it the case that someone could have heavy chain and light chain disease simultaneously? In other words, an M-spike and also elevated kappa or lambda light chain values?
Answer: "Heavy chain disease" is not really an accurate term. The presence of an elevated single heavy chain and an elevated single light chain is the norm in multiple myeloma.
An M-spike simply measures your abnormal heavy chains (in your case, the monoclonal versions of your IgG). Your quantified IgG lab result gives you the total of your normal IgG and the abnormal IgG (i.e. Quantified IgG = normal IgG + M-spike).
Almost always, only one of your immunoglobulins (heavy chains) is elevated in multiple myeloma (there are rare circumstances where more than one can be elevated, but I won't go into that here). When this occurs, it is almost always accompanied by the elevation of one of your free light chains (either kappa or lambda).
So, in your case you have IgG kappa type multiple myeloma and your other immunoglobulins and free light chains are either at normal levels or are suppressed. Again, this is the typical situation.
Some folks (about 20% of multiple myeloma patients), don't have a serum M-spike in relationship to their elevated free light chains and the amt of plasma cells in their bone marrow. This is called non-secretory or light-chain restricted disease and it is tracked through either bone marrow biopsies or via free light chain assays. Some folks only have a small M-spike in relationship to these other markers. This is called oligosecretory multiple myeloma. You don' have any of these versions since you started with a significant M-Spike.
In your case, you have run-of-the-mill multiple myeloma since you started with an M-spike and you simply beat down your abnormal IgG and your abnormal kappa free light chain (as well as the uninvolved Lambda free light chain) with chemo ...success!
As far as what a "weak band" (faint band) in the gamma region would translate to wrt other lab measurements, I really don't know, since it is a "weak band". That is, they aren't able to quantify the m-spike since it is so small, but it still appears graphically as a very small blip (spike) on your electrophoresis. This can just be perfectly normal and I wouldn't worry about it and would just continue to get routinely tested.
I would also suggest reading up more on the links that the staff published regarding thalidomide maintenance. I'm going to guess that Revlimid is not an option for you in the country you live in?
Hope this helps.
Answer: "Heavy chain disease" is not really an accurate term. The presence of an elevated single heavy chain and an elevated single light chain is the norm in multiple myeloma.
An M-spike simply measures your abnormal heavy chains (in your case, the monoclonal versions of your IgG). Your quantified IgG lab result gives you the total of your normal IgG and the abnormal IgG (i.e. Quantified IgG = normal IgG + M-spike).
Almost always, only one of your immunoglobulins (heavy chains) is elevated in multiple myeloma (there are rare circumstances where more than one can be elevated, but I won't go into that here). When this occurs, it is almost always accompanied by the elevation of one of your free light chains (either kappa or lambda).
So, in your case you have IgG kappa type multiple myeloma and your other immunoglobulins and free light chains are either at normal levels or are suppressed. Again, this is the typical situation.
Some folks (about 20% of multiple myeloma patients), don't have a serum M-spike in relationship to their elevated free light chains and the amt of plasma cells in their bone marrow. This is called non-secretory or light-chain restricted disease and it is tracked through either bone marrow biopsies or via free light chain assays. Some folks only have a small M-spike in relationship to these other markers. This is called oligosecretory multiple myeloma. You don' have any of these versions since you started with a significant M-Spike.
In your case, you have run-of-the-mill multiple myeloma since you started with an M-spike and you simply beat down your abnormal IgG and your abnormal kappa free light chain (as well as the uninvolved Lambda free light chain) with chemo ...success!
As far as what a "weak band" (faint band) in the gamma region would translate to wrt other lab measurements, I really don't know, since it is a "weak band". That is, they aren't able to quantify the m-spike since it is so small, but it still appears graphically as a very small blip (spike) on your electrophoresis. This can just be perfectly normal and I wouldn't worry about it and would just continue to get routinely tested.
I would also suggest reading up more on the links that the staff published regarding thalidomide maintenance. I'm going to guess that Revlimid is not an option for you in the country you live in?
Hope this helps.
-
Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi Multibily
Many thanks for the reply. Lifted a bunch of fog for sure!
I live in India and as you may know, most of the drugs have generic versions here and are relatively inexpensive so fortunately, I don't have an availability or cost issue in terms of what maintenance therapy to adopt. My doc suggested thalidomide because he says that too much lenalidomide during maintenance may prejudice a future SCT (as I have chosen to wait for 1st relapse before doing an SCT).
Another query for you if you don't mind - during my induction therapy (CyBorD), I have been (and continue to be) on a restricted diet (no raw food basically) because of fear of infection. Now that my induction is hopefully at an end and I am contemplating maintenance therapy, my query is - if I went onto thalidomide or lenalidomide maintenance, would that mean an effectively indefinite extension of this diet restriction ? I ask because I am a bit of a foodie BTW
Thanks in advance
Regards
Robin
Many thanks for the reply. Lifted a bunch of fog for sure!
I live in India and as you may know, most of the drugs have generic versions here and are relatively inexpensive so fortunately, I don't have an availability or cost issue in terms of what maintenance therapy to adopt. My doc suggested thalidomide because he says that too much lenalidomide during maintenance may prejudice a future SCT (as I have chosen to wait for 1st relapse before doing an SCT).
Another query for you if you don't mind - during my induction therapy (CyBorD), I have been (and continue to be) on a restricted diet (no raw food basically) because of fear of infection. Now that my induction is hopefully at an end and I am contemplating maintenance therapy, my query is - if I went onto thalidomide or lenalidomide maintenance, would that mean an effectively indefinite extension of this diet restriction ? I ask because I am a bit of a foodie BTW
Thanks in advance
Regards
Robin
Re: Hi everyone - new member with IgG kappa multiple myeloma
Interesting question about diet restrictions. Not sure I can answer that one as I have never really heard of anyone really limiting their diet for risk of infection wrt multiple myeloma. In the USA, many of us opt to do just the opposite and instead lean towards a diet of fresh vegetables and fruits for the health benefits.
But I understand the infection concern in India as I've traveled there a number of times. The food there is amazing, but sanitation concerns wrt food is a very real concern. Somebody else who has lived in a similar country with multiple myeloma may comment here?
There is always the concern that treating an SCT as a salvage approach (as you suggest) many not produce as robust an SCT-response as you might get if you did the SCT up front (I am smoldering, but have made a conscious decision to either never do an SCT or only consider an SCT for salvage therapy, if I should progress).
But I have never heard that Revlimid therapy would prejudice an SCT's success any more than another drug like Thalidomide. However, I can see a philosophy whereby somebody may start with Thalidomide and keep Revlimid in reserve if you should relapse or become refractory (it's always good to have a Plan B and Plan C mapped out should one of your current drugs cease to work).
There have been a lot of recent discussions on the forum regarding the tradeoffs of maintenance therapy and what the right drug is for that stage (or if you should even do any maintenance)...but most of the discussions have been around post-SCT maintenance therapy.
Perhaps some of the other forum readers can jump in here with their wisdom?
But I understand the infection concern in India as I've traveled there a number of times. The food there is amazing, but sanitation concerns wrt food is a very real concern. Somebody else who has lived in a similar country with multiple myeloma may comment here?
There is always the concern that treating an SCT as a salvage approach (as you suggest) many not produce as robust an SCT-response as you might get if you did the SCT up front (I am smoldering, but have made a conscious decision to either never do an SCT or only consider an SCT for salvage therapy, if I should progress).
But I have never heard that Revlimid therapy would prejudice an SCT's success any more than another drug like Thalidomide. However, I can see a philosophy whereby somebody may start with Thalidomide and keep Revlimid in reserve if you should relapse or become refractory (it's always good to have a Plan B and Plan C mapped out should one of your current drugs cease to work).
There have been a lot of recent discussions on the forum regarding the tradeoffs of maintenance therapy and what the right drug is for that stage (or if you should even do any maintenance)...but most of the discussions have been around post-SCT maintenance therapy.
Perhaps some of the other forum readers can jump in here with their wisdom?
-
Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Hi everyone - new member with IgG kappa multiple myeloma
Thanks again Multibily .
Just got the results of my retest -
At diagnosis, Kappa 141, Lambda 6.17, ratio 22.85, M-spike 2.6, Gamma globulins 3.5, bone biopsy 26% plasma cells.
After cycle 1, Kappa 18.2, Lambda 6.12, ratio 2.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After cycle 3, Kappa 14.2, Lambda 13.7, ratio 1.04. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.77
After cycle 4, Kappa 14.2, Lambda 1.12, ratio 11.6. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
RETEST 27 MARCH - Kappa 9.8, Lambda 1.26, ratio 7.8. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.76. MSpike 0.6, IgG 0.86 (normal 0.7 to 1.6 g / dl)
Light chains all over the place - but as you say, both chains have been pretty severely suppressed - not sure what to make of it all. Doc told me to put some more time between me and my last treatment cycle (i.e. 2 more weeks) and retest.
Any and all opinions and thoughts welcome as always
Regards
Robin
Just got the results of my retest -
At diagnosis, Kappa 141, Lambda 6.17, ratio 22.85, M-spike 2.6, Gamma globulins 3.5, bone biopsy 26% plasma cells.
After cycle 1, Kappa 18.2, Lambda 6.12, ratio 2.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After cycle 3, Kappa 14.2, Lambda 13.7, ratio 1.04. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.77
After cycle 4, Kappa 14.2, Lambda 1.12, ratio 11.6. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
RETEST 27 MARCH - Kappa 9.8, Lambda 1.26, ratio 7.8. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.76. MSpike 0.6, IgG 0.86 (normal 0.7 to 1.6 g / dl)
Light chains all over the place - but as you say, both chains have been pretty severely suppressed - not sure what to make of it all. Doc told me to put some more time between me and my last treatment cycle (i.e. 2 more weeks) and retest.
Any and all opinions and thoughts welcome as always
Regards
Robin
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi again everyone
Just got my serum retested - results as follows -
At diagnosis, Kappa 141, Lambda 6.17, ratio 22.85, M-spike 2.6, Gamma globulins 3.5, bone biopsy 26% plasma cells.
After cycle 1, Kappa 18.2, Lambda 6.12, ratio 2.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After cycle 3, Kappa 14.2, Lambda 13.7, ratio 1.04. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.77
After cycle 4, Kappa 14.2, Lambda 1.12, ratio 11.6. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89 (tests done 21st March)
RETEST 27 MARCH - Kappa 9.8, Lambda 1.26, ratio 7.8. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.76. MSpike 0.6, IgG 0.86 (normal 0.7 to 1.6 g / dl)
RETEST 10 APRIL - Kappa 14.8, Lambda 2.15, ratio 6.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.91. MSpike 0.7, IgG 0.99 (normal 0.7 to 1.6 g / dl)
(Normal values - Kappa 3.3 to 19.4, Lambda 5.7 to 26.3, Kappa / Lambda ratio 0.26 to 1.65)
I exchange emails with a Myeloma specialist in Raffles Hospital in Singapore and this is what he said about having a suppressed Lambda (non involved) chain -
'Usually, a suppressed globulin (immune suppression) is due to the effect of myeloma , rather than treatment. Excessive cancerous development of 1 protein may lead to a suppression of other non-involved proteins. Treatment is supposed to lift this suppression on the non-involved protein and not further suppress it'
So he basically seems to be saying that the suppressed Lambda value is a function of disease rather than (as I have read on this forum) a function of universal suppression of everything (Kappa, Lambda, MSpike etc) following induction therapy
He suggests I do 2 more induction therapy cycles as he wants the MBand to either disappear or plateau. My doctor suggests the same thing followed by either (a) a few months of Lenalidomide maintenance (not too many months so as not to prejudice any future stem cell harvest) or (b) go straight to Velcade maintenance (bi weekly) for as long as I can tolerate it.
So what happens if the M Spike stays where it is (i.e 0.6 or thereabouts) irrespective of the additional cycles and / or maintenance? Can one just live with a 0.6 Mspike?
Grateful for advice (would also appreciate of any of the docs on this forum also advise / comment)
Robin
Just got my serum retested - results as follows -
At diagnosis, Kappa 141, Lambda 6.17, ratio 22.85, M-spike 2.6, Gamma globulins 3.5, bone biopsy 26% plasma cells.
After cycle 1, Kappa 18.2, Lambda 6.12, ratio 2.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89
After cycle 3, Kappa 14.2, Lambda 13.7, ratio 1.04. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.77
After cycle 4, Kappa 14.2, Lambda 1.12, ratio 11.6. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.89 (tests done 21st March)
RETEST 27 MARCH - Kappa 9.8, Lambda 1.26, ratio 7.8. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.76. MSpike 0.6, IgG 0.86 (normal 0.7 to 1.6 g / dl)
RETEST 10 APRIL - Kappa 14.8, Lambda 2.15, ratio 6.9. SPEP shows 'weak band' in Gamma region, Gamma globulins 0.91. MSpike 0.7, IgG 0.99 (normal 0.7 to 1.6 g / dl)
(Normal values - Kappa 3.3 to 19.4, Lambda 5.7 to 26.3, Kappa / Lambda ratio 0.26 to 1.65)
I exchange emails with a Myeloma specialist in Raffles Hospital in Singapore and this is what he said about having a suppressed Lambda (non involved) chain -
'Usually, a suppressed globulin (immune suppression) is due to the effect of myeloma , rather than treatment. Excessive cancerous development of 1 protein may lead to a suppression of other non-involved proteins. Treatment is supposed to lift this suppression on the non-involved protein and not further suppress it'
So he basically seems to be saying that the suppressed Lambda value is a function of disease rather than (as I have read on this forum) a function of universal suppression of everything (Kappa, Lambda, MSpike etc) following induction therapy
He suggests I do 2 more induction therapy cycles as he wants the MBand to either disappear or plateau. My doctor suggests the same thing followed by either (a) a few months of Lenalidomide maintenance (not too many months so as not to prejudice any future stem cell harvest) or (b) go straight to Velcade maintenance (bi weekly) for as long as I can tolerate it.
So what happens if the M Spike stays where it is (i.e 0.6 or thereabouts) irrespective of the additional cycles and / or maintenance? Can one just live with a 0.6 Mspike?
Grateful for advice (would also appreciate of any of the docs on this forum also advise / comment)
Robin
Re: Hi everyone - new member with IgG kappa multiple myeloma
Hi everyone
Would be grateful for any advice on the above post - in a nutshell,
(1) What is the significance of a lower than normal Lambda reading of 2.6 (this being the uninvolved chain) but normal Kappa reading (the involved chain) - but as a result, an abnormal ratio?
(2) What may cause an uninvolved chain to go below normal after induction therapy? Is it the treatment itself that is causative of this?
(3) If it is the ratio that is so important, then what happens if both Kappa and Lambda are abnormal, but their ratio within the normal range?
(4) I started out with an M Spike of 2.6, which reduced to 0.6 / 0.7 after 1 cycle and has stayed there till the end of the 4th cycle. Am I to assume that this has now plateaued? Or do I need more therapy? If more therapy, can my Lambda reading get even more suppressed that it currently is (and the ratio even more abnormal?)
(5) If my MSpike stays where it is at 0.6, what does one make of this? Is it possible to just live with it? Can maintenance meds lower it?
Thanks in advance !
Robin
Would be grateful for any advice on the above post - in a nutshell,
(1) What is the significance of a lower than normal Lambda reading of 2.6 (this being the uninvolved chain) but normal Kappa reading (the involved chain) - but as a result, an abnormal ratio?
(2) What may cause an uninvolved chain to go below normal after induction therapy? Is it the treatment itself that is causative of this?
(3) If it is the ratio that is so important, then what happens if both Kappa and Lambda are abnormal, but their ratio within the normal range?
(4) I started out with an M Spike of 2.6, which reduced to 0.6 / 0.7 after 1 cycle and has stayed there till the end of the 4th cycle. Am I to assume that this has now plateaued? Or do I need more therapy? If more therapy, can my Lambda reading get even more suppressed that it currently is (and the ratio even more abnormal?)
(5) If my MSpike stays where it is at 0.6, what does one make of this? Is it possible to just live with it? Can maintenance meds lower it?
Thanks in advance !
Robin
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