Leading myeloma specialists from across Europe recently published an article in the journal The Oncologist that summarized the current treatment options and availability of therapeutic agents for multiple myeloma patients in Europe. This article, Part 4 in the series, summarizes the European authors’ recommendations for the management of side effects.

The European authors provided recommendations for managing side effects related to novel agent use in myeloma patients. The recommendations are similar to how the side effects are managed in the United States.

Blood Clots

Blood clots are one of the most significant side effects associated with thalidomide (Thalomid) and Revlimid (lenalidomide). After a piece of a blood clot breaks off, it may travel through the vein and potentially block an artery to the lungs.

Clots are particularly common when thalidomide or Revlimid are used in combination with steroids, chemotherapy, or erythropoiesis-stimulating agents.

In order to prevent blood clots, patients are advised to take aspirin, low-molecular weight heparin, or warfarin (Coumadin) at either the full dose or a fixed low dose. The authors recommended heparin for patients who are at a higher risk for blood clots or who are also receiving high-dose dexamethasone (Decadron) or doxorubicin (Adriamycin).

Alternatively, for patients who have a history of developing blood clots, Velcade (bortezomib) may be a better treatment choice than thalidomide or Revlimid, since it is not associated with blood clots.

Peripheral Neuropathy

Nerve damage in the extremities, known as peripheral neuropathy, is a serious and sometimes debilitating side effect that is associated with Velcade and thalidomide. Peripheral neuropathy can cause tingling or pain in the hands, feet, or legs.

However, not all patients develop peripheral neuropathy from these drugs, and the effect tends to show up quickly—patients who do not develop peripheral neuropathy in the first four to six cycles of Velcade treatment are unlikely to develop this side effect with more Velcade treatment.

Furthermore, peripheral neuropathy associated with Velcade may be reversible. The European physicians cited a trial in which 60 percent of patients with peripheral neuropathy recovered completely within a median time of 5.7 months.

The risk for developing peripheral neuropathy from thalidomide use, however, increases with prolonged use of thalidomide.

For both drugs, the article authors advised reducing the dosage at the first sign of increased tingling. If peripheral neuropathy continues, especially in the case of thalidomide, discontinuation of treatment may be necessary. Since Revlimid is not associated with neuropathy, it may be a useful treatment for patients with a history of peripheral neuropathy.

Cytopenia

Patients may develop cytopenia, or a reduction in the number of blood cells, from treatment with Revlimid or Velcade.

Neutropenia, or low white blood cell count, is associated with Revlimid use. The article authors wrote that doctors may respond by reducing the Revlimid dosage, discontinuing treatment, or administering growth factors.

Thrombocytopenia, or low platelet count, is associated with Velcade. The complication is cyclical, and a patient may recover during the rest period of a treatment cycle. “Intervention may not be necessary,” wrote the European researchers. However, if needed, patients with thrombocytopenia can have their Velcade dosage reduced or can temporarily stop treatment.

Bone Disease

Myeloma patients frequently experience myeloma-related bone disease, which can cause pain and fractures.

The article authors advised that patients who are suffering from lytic bone disease should take bisphosphonates for two years. Lytic bone disease is characterized by the destruction of an area of bone.

Proactive management is needed to prevent kidney failure (caused by myeloma-related bone disease) and bone disease of the jaw (a potential complication of bisphosphonates).

For more information, please read the article in the journal The Oncologist (abstract) or the other articles in this series. Part 1 compares availability of myeloma treatments in Europe and the U.S., Part 2 summarizes the European authors’ treatment recommendations for newly diagnosed patients, and Part 3 summarizes recommendations for relapsed patients.