Multiple Myeloma: Supportive Care for Elderly Patients

Ravi Vij, MD:In the elderly, supportive care measures are very important. We know that patients who are treated with our modern therapies, although they are safer, can still develop side effects. So, we often have to use drugs to support blood counts, especially in the initial phases of treatment. We may choose to reduce their dosage of the drugs, but often use of growth factors may help carry patients through a brief period of cytopenia.

We use drugs to help improve the hematocrit. The use of supported growth factors, especially if the hemoglobin is less than 10, is an appropriate intervention. Also, we know that patients with multiple myeloma have fairly impressive damage to their bones, often at the time of presentation. So, the use of either bisphosphonates or, more recently, the approval of denosumab for bone health preservation is another area that we should not neglect in elderly patients especially.

Certainly, the use of supportive care to counteract some of the side effects of our treatment is also an area that merits commenting upon. But if you have patients starting to develop neuropathy, one needs to be aggressive about dosage reductions and delays, especially with bortezomib (Velcade), and the use of drugs like Neurontin (gabapentin) or Lyrica (pregabalin) is often what we resort to as treatment for neuropathy. Also, one should not forget that for those patients who are on lenalidomide, one does need to have some strategy to prevent venous thromboembolism. For the majority, it is felt that the use of a low-dosage aspirin is adequate. But for people who have higher risk for thromboembolism, full anticoagulation with either a low molecule rate heparin or older anticoagulants may be necessary.

This patient achieved a very good partial response, which I think is, for this patient, probably a good measure of depth of response to try to achieve. Certainly, in patients who are transplant-eligible these days, we are often talking about aiming for even deeper levels of response with a minimal residual disease negativity—often now being talked of as an endpoint to strive for. Though that has not been validated as a strategy in the elderly patients, I think that often, the use of agents in this population, especially our current 2-drug regimens, will probably not in most cases allow us to achieve those depths of response. I don’t think that, at this time, there is data to suggest that we need to do so. We have to, certainly in this population, balance depth and efficacy with quality of life.

Transcript edited for clarity.

CASE: A 72-year-old Caucasian Man With Relapsed Multiple Myeloma

September 2016

• Patient history: At the age of 72, a Caucasian man was diagnosed with multiple myeloma; R-ISS stage I
• Other relevant history includes hypertension and difficulty walking up stairs
• He was treated with lenalidomide/dexamethasone and achieved a VGPR
• Treatment duration was 9 months; patient subsequently discontinued therapy 12 months ago

June 2018

• On routine follow-up, patient complains of increasing problems with fatigue, and has rising levels of M protein
• Laboratory results:
  • Hb, 9.6 g/dL
  • Ca²⁺9.2 mg/dL
  • Creatinine, 0.8 mg/dL
  • M-protein, 3.0 g/dL
  • 30% plasma cells in bone marrow
• Cytogenetics/FISH: del(17p)
• ECOG PS: 2