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Wednesday, 4 December 2013

Multiple myeloma – Treatments of symptoms In conventional medicine perspective

Multiple myeloma. also known as plasma cell myeloma or Kahler’s disease, is a types of abnormal growth of plasma cells collected in the none marrow where they grow and multiple to interfere with the production of normal blood cells. Paraprotein, an abnormal antibody produced by the plasma cell myeloma not only can cause kidney problem but also interference with the Roche automated total bilirubin assay caused by precipitate formation of that can cause clinical confusion, according to the study by the Harvard Medical School, Boston(1). Other study indicated that the production of paraproteins caused spurious results on individual analytes including total bilirubin (TBIL), direct bilirubin (DBIL), or HDL-cholesterol (HDL-C)(b). there is also a report of a 50 years old
chloride resistant metabolic alkalosis in a patient with hypercalcemia related to Multiple Myeloma (MM)(c).
A.4. A.4. Treatments of symptoms
1. Painful vertebral compression
Patients with painful vertebral compression fractures produced by multiple myeloma (MM) often experience reduction in pain after spinal augmentation with kyphoplasty or vertebroplasty. According to the study by The University of Texas MD Anderson Cancer Center, pain reduction after spinal augmentation with vertebroplasty or kyphoplasty was positively associated with reduction in other patient-reported cancer-related symptoms. Future studies of these augmentation procedures should measure multiple symptoms, in addition to pain and functional status(61). Patients of Multiple myeloma with common symptoms of back back may be prescribed by apin reliever or a back brace.
2. Infection
Multiple myeloma (MM) is a malignancy of clonal plasma cells, resulting in an increased production of ineffective immunoglobulins with suppression of non-involved immunoglobulins. According to the study by The Abbott Northwestern Hospital, Minneapolis, administering TMP-SMX for the first 2 months of initial chemotherapy is effective, inexpensive prophylaxis for early bacterial infection in multiple myeloma(62).
For parients of Mutliple myeloma with complication of infection, antibiotics may be necessary
3. Renal impairment
Renal impairment is a common complication of multiple myeloma (MM) and is supported in virtually all patients by a tubulointerstitial pathology that results from high serum concentrations of monoclonal free light chains (FLCs). According to the study by the UCL Centre for Nephrology, Royal Free Hospital, The mainstay of therapy is presently the removal of aggravating factors (dehydration, hypercalcaemia, nephrotoxic drugs) and the prompt institution of rapidly acting novel chemotherapy combinations. This approach allows the rescue of kidney function in more than two-thirds of patients. High cut-off haemodialysis dialysers may potentially add clinical benefits and the outcomes of controlled trials are eagerly awaited(63).
But other study indicated that if a patient with cast nephropathy and severe acute kidney injury remains dialysis-dependent, the prognosis is poor. A prompt diagnosis and commencement of effective chemotherapy is a critical determinant of renal recovery. A randomized controlled trial of high cut-off haemodialysis in patients with cast nephropathy, who all receive bortezomib-based chemotherapy, is underway(64).
4. Bone diseases
Bone disease associated with multiple myeloma(MM)is characterized by increased osteoclast activity and suppressed osteoclast function because of some factors produced by myeloma cells, leading to severe osteolytic lesions. According to the study by Tochigi Cancer Center, Tochigi, Japan, good control of MM itself is very important in order to manage bone lesions caused by MM. Bisphosphonate(BP), a potent inhibitor of osteoclast activity and function, should be used as adjunctive therapy for MM bone disease. Recently, the MRC Myeloma IX trial demonstrated improved survival and delayed disease progression with the use of an intravenous BP, zoledronate, in patients with newly diagnosed MM. Its results may lead to an alteration of guidelines for BP treatments of MM(65).
Other study also indicated that of treatment of bone diseases of which intravenous pamidronate and zoledronic acid are equally effective in reducing SREs, whereas zoledronic acid seems to offer survival benefits in symptomatic patients. Caution is needed to avoid adverse events, such as renal impairment and osteonecrosis of the jaw. Novel antiresorptive agents, such as denosumab, have given encouraging results, but further studies are needed before their approval for managing myeloma bone disease. Combination approaches with novel antimyeloma agents, such as bortezomib (which has anabolic effects on bone) with bisphosphonates or with drugs that enhance osteoblast function, such as antidickkopf-1 agents, antisclerostin drugs, or sotatercept, may favorably alter our way of managing myeloma bone disease in the near future(66).
5. Anemia
Hepcidin is the principal iron-regulatory hormone and a pathogenic factor in anemia of inflammation. Patients with multiple myeloma (MM) frequently present with anemia. According to the Department of Hematology and Immunology, Vrije Universiteit Brussel, Brussels, treatment options for anemic myeloma patients include red blood cell (RBC) transfusions and recombinant human erythropoietin (rHuEPO).
5.1. Red blood cell transfusions convey an immediate effect and rapidly increase the patient’s hemoglobin level. Unfortunately, effects of RBC transfusions are only transient and can be associated with several risks, including infections and mild to even life-threatening immunologic reactions.
5.2. rHuEPO is biologically equivalent to the human endogenous hormone EPO, and its application leads to an increase of hemoglobin levels over an extended time without the risks of blood transfusions. Several studies reported a significant improvement of erythropoiesis, reduction in transfusion need, and improved quality of life by using rHuEPO as long-term treatment of myeloma-associated anemia. Recently, an international expert panel recommended the use of rHuEPO for anemic myeloma patients where other possible causes of anemia have been eliminated(67).
1. Painful vertebral compression
Patients with painful vertebral compression fractures produced by multiple myeloma (MM) often experience reduction in pain after spinal augmentation with kyphoplasty or vertebroplasty. According to the study by The University of Texas MD Anderson Cancer Center, pain reduction after spinal augmentation with vertebroplasty or kyphoplasty was positively associated with reduction in other patient-reported cancer-related symptoms. Future studies of these augmentation procedures should measure multiple symptoms, in addition to pain and functional status(61). Patients of Multiple myeloma with common symptoms of back back may be prescribed by apin reliever or a back brace.
2. Infection
Multiple myeloma (MM) is a malignancy of clonal plasma cells, resulting in an increased production of ineffective immunoglobulins with suppression of non-involved immunoglobulins. According to the study by The Abbott Northwestern Hospital, Minneapolis, administering TMP-SMX for the first 2 months of initial chemotherapy is effective, inexpensive prophylaxis for early bacterial infection in multiple myeloma(62).
For parients of Mutliple myeloma with complication of infection, antibiotics may be necessary
3. Renal impairment
Renal impairment is a common complication of multiple myeloma (MM) and is supported in virtually all patients by a tubulointerstitial pathology that results from high serum concentrations of monoclonal free light chains (FLCs). According to the study by the UCL Centre for Nephrology, Royal Free Hospital, The mainstay of therapy is presently the removal of aggravating factors (dehydration, hypercalcaemia, nephrotoxic drugs) and the prompt institution of rapidly acting novel chemotherapy combinations. This approach allows the rescue of kidney function in more than two-thirds of patients. High cut-off haemodialysis dialysers may potentially add clinical benefits and the outcomes of controlled trials are eagerly awaited(63).
But other study indicated that if a patient with cast nephropathy and severe acute kidney injury remains dialysis-dependent, the prognosis is poor. A prompt diagnosis and commencement of effective chemotherapy is a critical determinant of renal recovery. A randomized controlled trial of high cut-off haemodialysis in patients with cast nephropathy, who all receive bortezomib-based chemotherapy, is underway(64).
4. Bone diseases
Bone disease associated with multiple myeloma(MM)is characterized by increased osteoclast activity and suppressed osteoclast function because of some factors produced by myeloma cells, leading to severe osteolytic lesions. According to the study by Tochigi Cancer Center, Tochigi, Japan, good control of MM itself is very important in order to manage bone lesions caused by MM. Bisphosphonate(BP), a potent inhibitor of osteoclast activity and function, should be used as adjunctive therapy for MM bone disease. Recently, the MRC Myeloma IX trial demonstrated improved survival and delayed disease progression with the use of an intravenous BP, zoledronate, in patients with newly diagnosed MM. Its results may lead to an alteration of guidelines for BP treatments of MM(65).
Other study also indicated that of treatment of bone diseases of which intravenous pamidronate and zoledronic acid are equally effective in reducing SREs, whereas zoledronic acid seems to offer survival benefits in symptomatic patients. Caution is needed to avoid adverse events, such as renal impairment and osteonecrosis of the jaw. Novel antiresorptive agents, such as denosumab, have given encouraging results, but further studies are needed before their approval for managing myeloma bone disease. Combination approaches with novel antimyeloma agents, such as bortezomib (which has anabolic effects on bone) with bisphosphonates or with drugs that enhance osteoblast function, such as antidickkopf-1 agents, antisclerostin drugs, or sotatercept, may favorably alter our way of managing myeloma bone disease in the near future(66).
5. Anemia
Hepcidin is the principal iron-regulatory hormone and a pathogenic factor in anemia of inflammation. Patients with multiple myeloma (MM) frequently present with anemia. According to the Department of Hematology and Immunology, Vrije Universiteit Brussel, Brussels, treatment options for anemic myeloma patients include red blood cell (RBC) transfusions and recombinant human erythropoietin (rHuEPO).
5.1. Red blood cell transfusions convey an immediate effect and rapidly increase the patient’s hemoglobin level. Unfortunately, effects of RBC transfusions are only transient and can be associated with several risks, including infections and mild to even life-threatening immunologic reactions.
5.2. rHuEPO is biologically equivalent to the human endogenous hormone EPO, and its application leads to an increase of hemoglobin levels over an extended time without the risks of blood transfusions. Several studies reported a significant improvement of erythropoiesis, reduction in transfusion need, and improved quality of life by using rHuEPO as long-term treatment of myeloma-associated anemia. Recently, an international expert panel recommended the use of rHuEPO for anemic myeloma patients where other possible causes of anemia have been eliminated(67).
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/12521367
(b) http://www.ncbi.nlm.nih.gov/pubmed/18251580
(c) http://www.ncbi.nlm.nih.gov/pubmed/22073517
(61) http://www.ncbi.nlm.nih.gov/pubmed/22543044
(62) http://www.ncbi.nlm.nih.gov/pubmed/8678082.
(63) http://www.ncbi.nlm.nih.gov/pubmed/23114897
(64) http://www.ncbi.nlm.nih.gov/pubmed/20827195
(65) http://www.ncbi.nlm.nih.gov/pubmed/22902442
(66) http://www.ncbi.nlm.nih.gov/pubmed/21483016
(67) http://www.ncbi.nlm.nih.gov/pubmed/16163188