European myeloma experts recently developed guidelines for the appropriate management of side effects associated with novel agent therapy for older multiple myeloma patients. This article, Part 2 in a series, summarizes the guidelines for the management of thalidomide-related side effects. Part 1 ^[1] describes the guidelines for the management of Velcade-related side effects, Part 3 ^[2] summarizes the guidelines for the management of Revlimid-related side effects, and Part 4 ^[3] summarizes recommendations on novel agent use in specific patient populations.

Management Of Thalidomide-Related Side Effects

Low Platelet Counts: 

Patients treated with thalidomide ^[4] (Thalomid) commonly experience blood-related side effects, but according the European experts, they can usually be managed through standard supportive care.

The experts recommended that patients experiencing low platelet counts should be regularly monitored.

Low White Blood Cell Counts:

For patients experiencing low white blood cell counts, the experts recommended that they take granulocyte colony-stimulating factor (G-CSF) as a primary or secondary preventative treatment to reduce the severity of the side effect.

Low Red Blood Cell Counts:

For patients who have low red blood cell counts (hemoglobin levels below 10 g/dL) as a result of thalidomide treatment, the experts recommended that the patients undergo red blood cell transfusions.

Patients may also be treated with red blood cell-stimulating agents. However, the experts noted that red blood cell-stimulating agents increase the risk of blood clots. They, therefore, advised caution in the use of these agents in patients receiving thalidomide therapy. They also stated that therapy with red blood cell-stimulating agents should be discontinued if hemoglobin levels reach 12 g/dL.

Blood Clots:

According to the experts, thalidomide does not appear to increase the risk of formation of blood clots as a single agent. However, when used in combination with melphalan ^[5] (Alkeran) plus prednisone ^[6] or Revlimid ^[7] (lenalidomide) plus dexamethasone ^[8] (Decadron), the risk of blood-clotting events is significantly increased. In these cases, the experts recommended that patients receive preventative treatment with aspirin, warfarin, or heparin.

Peripheral Neuropathy:

Between 6 percent and 54 percent of patients treated with thalidomide experience peripheral neuropathy, condition in which nerve damage in the extremities causes tingling or pain in the hands, arms, feet, or legs. According to the experts, it is the most clinically relevant side effect of long-term thalidomide use.

The experts recommended that patients be carefully monitored for symptoms before and during treatment. Symptoms typically emerge after about ten months of treatment, and the risk of peripheral neuropathy increases with extended use of thalidomide. Since there is currently no treatment for peripheral neuropathy available, the experts noted that the complication is best managed with dose modifications.

Gastrointestinal Complications:

Gastrointestinal complications, such as nausea, vomiting, diarrhea, or constipation, are common in patients receiving treatment with thalidomide. The experts pointed out that these side effects can be managed with anti-vomiting drugs, anti-diarrhea drugs, and laxatives. According to the experts, dose reductions or treatment interruptions are rarely necessary.

Infection:

According to the study authors, infections such as pneumonia are a particular concern among older patients. They pointed out that approximately 5 percent of older patients who received treatment with melphalan, prednisone, and thalidomide experienced severe infections. They recommended appropriate anti-infective treatment for cases of severe infections.

Skin Reactions:

For patients treated with thalidomide, about 3 percent experience skin reactions. In severe cases, the experts recommended that patients permanently discontinue thalidomide treatment.

For more information, please refer to the original study in the journal Blood Reviews ^[9] (abstract).