Presentation Outline ICHP Annual Meeting September 13-15

Case 2
ST is a 76 y/o African American female who recently presented to
her PCP for increasing pain in her back. PMH: Type 2 DM, HTN, CAD
s/p stents, depression. ST was diagnosed with Stage IIIa IgG lambda
multiple myeloma based on the following labs and exams:
• WBC: 12 X 109 /L
• ß₂-microglobulin: 7 mcg/mL
• Serum creatinine: 1.7 mg/dL • IgM: 9 (4-350 mg/dL)
• Hemoglobin: 8 gm/dL
• Calcium: 12 mg/dL
• Platelets: 112 X 109 /L
• Albumin: 4 g/dL
• IgA: 5 (50-370 mg/dL)
• IgG: 6080 (620-1520 mg/dL)
• � free light chains: 306 (0.57-2.63 mg/dL)
• Plasma viscosity: 2.47 X 10−3 (1.35-1.85)
• Skeletal survey shows multiple lytic lesions T8-T11
Palumbo A, et al. Blood. 2011;118(17):4519‐4529.
Case 2: Patient ST
• She also has prexisting diabetes with
peripheral neuropathy on gabapentin
300mg TID.
• What is your recommendation?
Assessment for Vulnerability in
Newly-Diagnosed MM Patients
Presence of chronic
diseases or conditions
Comorbidity
Actions
• Consider drug interactions
• Incompatibility of treatment
• Minimize risk of frailty
• Minimize risk of disability
Palumbo A, et al. Blood. 2011;118(17):4519‐4529.
Limits in the major
life activities due to
physical or mental
impairment
Disability
Case 2
Weight loss, fatigue,
low activity, slow
motor balance and
gait
Actions
Frailty
• Need for supportive service
• Minimize risk of mortality
• Decrease risk of hospitalization)
• It has been decided to treat ST with
lenalidomide + bortezomib + dexamethasone
(RVD)
• Lenalidomide 25 mg days 1-21 + low-dose vs.
high dose dexamethasone Q28days
– Low dose: 40 mg days 1, 8, 15, 22
– High dose: 40 mg days 1-4, 9-12, 17-20
– N = 445
– 1- year OS = 87% (high dose) vs. 96% (low dose) , P
= .0002
– DVT = 26% vs. 12%, P = .0003
– Infection or pneumonia = 16% vs. 9%, P = .04
– Fatigue = 15% vs. 9%, P = .08
Rajkumar SV, et al. Lancet Oncol. 2010;11(1):29‐37.
Peripheral Neuropathy (PN)
• Higher risk of PN
– In patients presenting with subclinical PN
– After prolonged therapy
– In elderly patients
• Clinical manifestations include sensory symptoms,
motor symptoms, and autonomic dysfunction
Severity Action
Grade 1 Continue as scheduled
Grade 1 w/ pain or grade 2 Reduce dose per course to 1.0 mg/m2 Grade 2 w/ pain or grade 3 Withhold bortezomib treatment until PN resolves,
reinitiate at a dose of 0.7 mg/m2 once weekly
Grade 4 Discontinue therapy
Palumbo A, et al. Blood. 2008;111:3968‐3977.
Argyriou AA, et al. Blood. 2008;112:1593‐1599.
Bortezomib Dose Modification with PN