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 4 in the series, covers the experts’ recommendations on novel agent use in specific patient populations.

In general, the European experts recommended that older patients with other diseases see a specialist for that specific disease before starting treatment with the novel agents Velcade ^[1] (bortezomib), thalidomide ^[2] (Thalomid), and Revlimid ^[3] (lenalidomide) as well as once treatment has started to assess the impact of treatment on the other diseases.

In addition, they summarized recent findings for the following specific patient populations.

Patients With Kidney Impairment:

According to the experts, Velcade is an effective and well-tolerated treatment for myeloma patients with kidney impairment ^[4]. When used in combination with melphalan plus prednisone, it has been shown to reverse kidney impairment at a faster rate than melphalan plus prednisone alone.

The experts pointed out that limited data is available on the use of thalidomide in patients with impaired function. However, results of a few small studies indicate that thalidomide is highly active and well tolerated in this patient population. In addition, thalidomide has been shown to reverse kidney impairment. However, the experts also noted that elevated calcium levels have also been reported in patients with impaired kidney function. They therefore recommended that thalidomide should only be used during clinical trials for these patients.

Revlimid is removed from the body by the kidneys, so the experts advised that it is critical that patients with kidney impairment are regularly monitored if treated with Revlimid. In addition, they also recommended that the Revlimid dosage be reduced.

Patients With Liver Impairment:

Patients with moderate and severe liver impairment should undergo Velcade treatment with caution. Patients should also consider reducing the Velcade dosage.

According to the experts, thalidomide and Revlimid have not been studied in patients with liver impairment.

Patients With Bone Disease:

Patients with bone disease ^[5] should receive treatment with bisphosphonates ^[6]. Research has also shown that elderly patients treated with Velcade, melphalan, and prednisone had a lower rate of skeletal side effects, lower use of bisphosphonates, and increased activity of cells that are responsible for bone formation.

Patients Over The Age Of 75:

According to the experts, elderly myeloma patients over the age 75 may significantly benefit from treatment with novel agents. However, they pointed out that further dose modifications may be needed due to increased risk of side effects. If severe side effects occur, the experts advised that treatment should be stopped until side effects subside. Once treatment is restarted at lower doses, they recommended additional supportive care for patients at high risk for severe side effects.

For more information, please refer to the original study in the journal Blood Reviews ^[7] (abstract).