Multiple myeloma

A small amount of paraprotein without any damage. A precursor, not cancer: only regular monitoring is needed; about 1 in 100 progress each year.

More paraprotein or marrow plasma cells, but no organ damage. Monitored closely; high-risk patients may be offered treatment.

Causes CRAB or other damage. Needs treatment.

Plasmacytoma: a single lump of myeloma cells, treated with radiotherapy. AL amyloidosis: abnormal protein deposits in the heart, kidneys or nerves, treated with myeloma-type medicines.

Serum protein electrophoresis, immunofixation and serum free light chains measure the abnormal protein. They are repeated to follow treatment.

Shows the percentage of myeloma cells. FISH finds high-risk changes such as t(4;14), del(17p) and 1q gain.

Whole-body low-dose CT, PET-CT or MRI shows bone damage; more sensitive than X-rays.

Calcium, creatinine, haemoglobin, albumin, beta-2 microglobulin and LDH (these give the stage).

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• The FISH results decide how intensive the treatment should be.
• If calcium is high or kidneys are affected, these are treated urgently while other results come.

Low beta-2 microglobulin, normal albumin, no high-risk FISH changes, normal LDH. Best outlook.

Between stage I and III.

High beta-2 microglobulin with high-risk FISH changes or high LDH.

1. Induction for about 4 to 6 cycles: daratumumab, bortezomib, lenalidomide and dexamethasone (D-VRd); VRd or VCd are lower-cost options.
2. Collection of your own stem cells.
3. High-dose melphalan with autologous stem cell transplant.
4. Maintenance with lenalidomide (sometimes with daratumumab) for years.

Side effects: myeloma medicines · transplant

1. Daratumumab with lenalidomide and dexamethasone (DRd), or D-VRd, or VRd.
2. Treatment continues as long as it works.

Side effects: myeloma medicines

1. A different combination: carfilzomib, pomalidomide, daratumumab or isatuximab with dexamethasone.
2. BCMA-targeted treatments: CAR-T (cilta-cel, ide-cel), bispecific antibodies (teclistamab, elranatamab), or belantamab.

1. Bone-strengthening injection (zoledronic acid or denosumab), after a dental check.
2. Radiotherapy for painful bones or spinal cord compression; vertebroplasty for collapsed vertebrae.
3. Kidney protection: plenty of fluids, avoid NSAIDs and contrast where possible.
4. Aciclovir to prevent shingles; aspirin or blood thinner with lenalidomide to prevent clots.

• Bortezomib: numbness and tingling (less with weekly injections under the skin); shingles (aciclovir prevents it).
• Lenalidomide: low counts, loose stools, rash, and blood clots.
• Dexamethasone: high sugar, poor sleep, mood changes, increased appetite.
• Daratumumab: reactions during the first dose; it affects blood bank cross-matching, so carry your blood group card and tell the blood bank.
• Carfilzomib: high blood pressure and heart effects.

• High-dose melphalan causes mouth sores, loose stools, hair loss and very low counts for about 2 weeks.
• About 2 to 3 weeks in hospital; recovery over a few months.

• Drink 2 to 3 litres of fluid a day (unless told otherwise) to protect the kidneys.
• Avoid painkillers like ibuprofen and diclofenac.
• Stay active but avoid heavy lifting and falls; a back brace may help.
• Dental check before bone injections; tell your dentist you are on them.

• Wash hands often; avoid crowds and people with coughs or fever when counts are low.
• Eat freshly cooked, hot food; avoid raw salads, cut fruit from outside, and street food during low counts.
• Keep the central line or PICC clean and dry, as taught.
• Vaccines (such as flu and pneumococcal) as advised; avoid live vaccines during treatment.

New back pain with weakness or numbness of the legs, or loss of bladder or bowel control (possible spinal cord compression): go to the emergency department immediately. Also: confusion, extreme thirst or drowsiness (high calcium), very little urine, fever of 38°C or more, or leg swelling.

When to seek help urgently