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Eyelid-Related Complications Of Velcade Therapy: New Insights And Recommendations
By: Maike Haehle; Published: May 23, 2019 @ 5:03 pm | Comments Disabled
A team of U.S. researchers has published the results of an investigation into eyelid-related complications in multiple myeloma patients receiving treatment with Velcade or Kyprolis. Drawing on the results of their investigation, the authors of the new study also propose guidelines for the prevention and management of such complications.
The authors report on a case series of 16 patients who developed either blepharitis or chalazia after starting treatment with Velcade (bortezomib) or Kyprolis (carfilzomib).
Blepharitis is the medical term for chronic inflammation of the eyelid, and a chalazion is a cyst in the eyelid caused by a blocked oil gland.
Both blepharitis and chalazia have previously been reported as occurring in patients treated with Velcade, and both Velcade and Kyprolis are in the proteasome inhibitor class of therapies, which also includes Ninlaro (ixazomib).
There were 11 women and 5 men in the researchers’ sample of 16 patients, suggesting that eyelid complications may be more likely to occur in female myeloma patients.
Fourteen of the 16 patients had one or more episodes of chalazia, and 10 of the patients had one or more episodes of blepharitis. It was common for patients to develop both of the eyelid-related complications. This occurred in 60 percent of the patients who developed chalazia and 80 percent of the patients who developed blepharitis.
The average time from the start of Velcade or Kyprolis treatment to the development of an eyelid complication was 103 days (3.4 months).
Because the researchers’ report was a retrospective analysis, the patients in their case series did not have their eyelid-related complications addressed in a consistent way. The approach to addressing the complications depended on the choice of the patients and their physicians.
In many cases, the eyelid complications were addressed solely with what the researchers describe as “ocular therapy.” This is treatment of the complication with warm compresses, oral or infused (“systemic”) antibiotics, antibiotic eye drops or ointments, or steroid eye drops or ointments.
In episodes where the researchers were able to document the treatment outcome, ocular therapy alone successfully resolved the eyelid-related complication 70 percent of the time.
Another approach to the eyelid-related complications was to start ocular therapy while also discontinuing treatment with the proteasome inhibitor the patient was on when the complication developed. In episodes with known outcomes, this approach successfully resolved the complication 73 percent of the time.
Recommendations For Prevention And Treatment
Based on their findings, the researchers propose an algorithm for the prevention and treatment of eyelid-related complications in patients being treated with Velcade.
As a first step, they recommend that patients starting treatment with Velcade be referred to an ophthalmologist for a baseline screening. They also recommend that patients be given information about eyelid hygiene and the potential for eyelid-related complications while being treated with Velcade.
If a patient being treated with Velcade develops chalazia or blepharitis, the researchers recommend immediate referral to an ophthalmologist, two months of ocular therapy, but no change in myeloma treatment. As initial ocular therapy, the study authors suggest hot compresses in combination with at least one topical antibiotic and/or steroid drop.
If this initial approach to the complications is not successful, the researchers recommend that ocular therapy be continued, Velcade therapy be discontinued, and consideration be given to switching the patient to an alternative proteasome inhibitor such as Kyprolis or Ninlaro.
If the complications persist even after switching to alternative myeloma therapy, the authors recommend a prolonged course of the antibiotic doxycycline, administered orally. They also recommend that a biopsy be carried out to more accurately determine the nature of complication.
If the complications finally resolve after the patient has been switched to a different myeloma therapy, the authors suggest that the option of switching the patient back to Velcade be considered.
Study Design And Results
The case series compiled by the study authors included data for 16 patients seen at Mount Sinai Hospital in New York City. All of the patients had either multiple myeloma (14 patients) or AL amyloidosis with MGUS (2 patients), and they developed eye complications between January 2010 and January 2017 while being treated with a proteasome inhibitor.
The average patient age was 62 years. Median follow-up time was 17 months.
All but one of the 16 patients was receiving a Velcade-containing combination therapy when they developed their first eyelid complication. The one non-Velcade patient was on a Kyprolis-containing treatment regimen.
Four of the patients (25 percent) developed their first eyelid complication during the first cycle of treatment. Average time from treatment exposure to the onset of the first eyelid complication was 3.4 months.
Overall, 14 patients (87.5 percent) developed chalazia, 10 patients (62 percent) developed blepharitis, and 8 patients (50 percent) developed both.
Of the 14 patients who had chalazia, 11 (79 percent) developed two or more concurrent lesions. Female patients were more likely to develop concurrent lesions.
The researchers observed 34 episodes of eyelid complications in total; 23 of those cases (68 percent) were chalazia and 11 cases (32 percent) were blepharitis.
The two most common approaches to dealing with these complications were ocular therapy alone and ocular therapy combined with stopping the patient’s treatment with Velcade.
The most common ocular therapies were warm compresses (18 episodes), antibiotic eye drops and/or ointments (12 episodes), systemic antibiotics (9 episodes), and steroid eye drops and/or ointments (4 episodes).
When ocular therapy alone was able to successfully address an eyelid-related complication, the average time until complication resolution was 55 days (1.8 months).
When the complication was successfully addressed through a combination of ocular therapy and discontinuing the patient’s original proteasome inhibitor, the average time until complication resolution was 93 days (3.1 months) after discontinuation of the patient’s original proteasome inhibitor.
Five of the 34 episodes of eyelid-related complications tallied in the study were not successfully resolved by the time the researchers carried out their analysis of the study results. The authors of the study point out, however, that this was not entirely unexpected because the study follow-up time was just 17 months. The authors therefore speculate that some of the unresolved episodes may eventually be resolved.
For more information, please see the study by Sklar, B. A. et al., “Management and outcomes of proteasome inhibitor associated chalazia and blepharitis: a case series,” in BMC Ophthalmology, May 14, 2019 (full text [1]).
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URL to article: https://myelomabeacon.org/news/2019/05/23/chalazia-blepharitis-velcade-case-series-recommendations/
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[1] full text: https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-019-1118-x
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