1. Myeloma Round Table Beth Faiman MSN, APRN-BC, AOCN Nurse Practitioner, Cleveland Clinic Pre-Doctoral Fellow, Case Western Reserve

2. Hematologic events: Neutropenia and Thrombocytopenia Neutropenia – Functional neutrophils are critical to the immune system – Neutropenia can occur from treatment or the disease itself – Educate signs and symptoms of infection Risk is primarily during times of low WBC or treatment with agents that lower immune function Miceli et al, 2008.

3. Hematologic events: Neutropenia and Thrombocytopenia Prophylactic antibiotic usage for neutropenia is controversial – Generally not done except during high-dose therapy (transplant setting) or if planned prolonged neutropenia in high-risk patients Treatment – Colony-stimulating factors increase WBC Sargramostim Filgrastim Peg-filgrastim – Treat the myeloma itself if disease related Miceli et al, 2008.

4. Thrombocytopenia Low blood platelets May be a result of treatment of disease itself (marrow crowded out by atypical plasma cells Signs: – Bleeding – Purpura – Petechiae Diagnosis – Low Platelet count (normal 150-400) Treatment – Watchful waiting – Treat disease – Platelet transfusion – Hold anti-myeloma therapy if indicated Bortezomib, lenalidomide, etc. UTI = urinary tract infection; IVIG = intravenous immunoglobulin; PCP = pneumocystis pneumonia. Paradisi et al, 2001; Kollef, 2008; Gooskens et al, 2009; Ferguson et al, 2009; Pneumovax ® prescribing information, 2009; Zostavax ® prescribing information, 2009.

5. Hypercalcemia and Bone Loss Hypercalcemia in 15% of patients – Increased calcium levels, dehydration can precipitate renal failure – Treat with pamidronate, hydration, treat the disease Pathobiology: Malignant cells produce osteoclast- activating factors that destroy bone cells – Osteoclast stimulation leads to extensive osteolysis, severe bone pain, and pathologic fractures – Spinal cord compression – Plasmacytoma with significant bone destruction Most visible aspect of myeloma – 80% of patients develop bone disease Roodman, 2008.

6. Hypercalcemia of Malignancy Symptoms – Altered LOC, constipation, coma Diagnosis: Confirm by measuring CSC mg/dL (4.0 – serum ALB g/dL) Serum calcium mg/dL + 0.8 Example Calcium = 11.0 mg/dL ALB = 3.0 mg/dL 4.0 - 3.0 = 1.0 a)Multiply (1.0) by 0.8, and add to the calcium of 11.0 CSC = 11.8 mg/dL LOC = level of consciousness; CSC = corrected serum calcium. Payne, 2004.

7. Renal Dysfunction Bence-Jones proteinuria: Incidence ~ 70% – Light chain Igs can precipitate and damage renal cells – Free light chains filtered in the nephron’s glomerulus, then absorbed and metabolized by proximal tubular cells – Heavy and light chains can cause renal tubular damage – sFLC assay more reliable than urine – ATN secondary to NSAIDS, dehydration, nephrotoxic agents (CT dyes) – Supportive therapy Hydration, correct underlying cause with treatment Avoid IV contrast and nephrotoxic agents (IV dyes, NSAIDS) Plasmapheresis, dialysis ATN = acute tubular necrosis; NSAIDS = non-steroidal anti-anflammatory drugs. Rajkumar et al, 2001; Dimopoulos et al, 2008; Botchler et al, 2008; Wong et al, 2007.