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The Complete Treatment Plan In Multiple Myeloma
Applying Local Radiation
A General Overview
The disease runs a chronic course extending over a few years, but relentlessly progresses to death. Blood urea level above 80 mg/dl (13 mmol/liter) hemoglobin below 7 g/dl and hypoalbuminemia are bad prognostic factors. Cases with blood urea above 80 mg/dl rarely survive a few months. Prognosis also varies with the different types of myeloma.
The drug of choice is the alkylating agent melphalan, which is a phenylalanine mustard. In a daily dose of 2 mg orally, it is effective in suppressing the disease, relieving symptoms and clearing the bony lesions over a period of 4-6 months. Maintenance therapy is required. Melphalan may produce adverse side effects like nausea, allergic manifestations, granulocytopenia and aplastic anemia. Combination with prednisolone in an oral dose of 1 mg/Kg/day improves the effectiveness by 20% and the median survival is further prolonged by 5 months and hence these drugs are combined. An intensive regimen with melphalan using 0.25 mg/Kg/day in combination with prednisolone 2 mg/Kg/day for four days, given in pulse doses once in 4-6 weeks has been used in many centers.
Cyclophosphamide given in an oral dose of 1-2 mg/day is a comparable alternative to melphalan. These drugs do not show cross resistance andhence when one of them fails, the other can be used.
Carmustine (BCNU), given in an intravenous dose of 150 mg/m2 once in 4-6 weeks is also effective. Various combination regimen have been devised for resistant cases. A regimen using sequential weekly administration of melphalan and prednisolone or cyclophosphamide and prednisolone in the usual doses, followed by a short pause and repeated over 6-8 courses has been found to be effective in resistant cases. Vincristine has been found to augment the beneficial effect.
Infections have to be treated promptly with antibiotic combinations. Hyperuricemia has to be prevented by the oral administration of allopurinol, 100 mg in three daily doses.
Renal complications of hyperuricemia can be avoided by hydrating the patient, alkalinizing, the urine by the administration of sodium bicarbonate and ensuring a daily urine output of at least 2 liters by the use of furosemide in small doses. Hemodialysis may be required to tide over acute renal failure.
Treating Adverse Effects
The adverse effects of hypercalcemia can be reversed by:
- Proper hydration
- Intravenous infusion of 1 liter of 0.1 M solution of mono and disodium phosphate and
- Administration of prednisolone, 2 mg/Kg orally or betamethasone, 4 mg intravenously every 8 hours.
Calcitonin in an intramuscular dose of 140- 280 MRC units 12 hourly reduces the serum calcium levels. Oral mono- and disodium phosphate 1-3 g/day reduces hypercalcemia. The results are not encouraging in a consistent manner. Dichloromethylene diphosphonate which is an inhibitor of osteoclastic activity has been found to reduce calcium mobilization from bone. This drug is under trial. Mithramycin, 50 ug/Kg on alternate days and sodium fluoride 100- 200 mg/day have been used to bring down hypercalcemia and to favour bone repair.
Hyperviscosity syndrome is treated by plasmapheresis using a blood cell separator. Administration of thiols inhibits the synthesis of myeloma proteins. Bleeding and fractures demand symptomatic treatment in addition. Spinal cord compression demands immediate laminectomy and irradiation to the spine.
A Patient In Plasmapheresis Therapy
Hyperviscosity syndrome Characteristics
Above 10 g/dl
Below 8.5 g/dl
Below 12 mg/dl
Above 12 mg/dl
X-ray of bones
Normal or sparse lesions
Advanced lytic lesions
M-Components, IgG, IgA
Below 5 g/dl Below 3 g/dl
Above 7 g/dl Above 5 g/dl
Treatment Of Localized Myeloma
Local radiation in a dose of 500- 1000 rads help to arrest the lesion. There is rapid pain relief and recovery is hasrened. It may be combined with chemotherapy. Total body irradiation using 110- 300 rads have been reported to be beneficial. Experimentally, bone marrow transplantation has also been tired with encouraging results.
Localised plasmacytomas have to be removed surgically and the patients have to be followed up for several years to watch for the development of multiple myeloma.
© 2014 Funom Theophilus Makama