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Follow-up care after treatment of multiple myeloma

Follow-up occurs usually at the hospital the patient belongs to. 

The goal of the follow-up is to identify new symptoms early and provide the patient with the best possible quality of life and as long lifespan as possible. The M-component is followed. A rising M-component is an sign of progression.

Follow-up care will focus on:

  • Anemia
  • Infections
  • Renal failure 
  • Hypercalcemia
  • Osteolytic lesions
  • Pain and fractures

Anemia

Some patients have anemia at the time of diagnosis. This does not always improve during treatment of the underlying disease. For anemia symptoms, transfusions or possibly erythropoietin injections are appropriate.

Infections

Patients generally have a reduced concentration of normal immunoglobulines which is often treated with corticosteroids and, in periods, may have severe neutropenia from chemotherapy. These patients are therefore more prone to infection and must be treated with antibiotics as soon as possible if symptoms and signs of infection develop.

Certain patients with recurring infections may benefit from substitution treatment with gammaglobulin. Indications for this type of treatment should be identified by a specialist. Some medications also increase the risk of viral infections such as herpes zoster.

Renal failure

Renal failure is observed in about 30% of patients, and in most patients, the kidneys are affected by the disease.

Serious renal failure requiring dialysis or other life-saving treatment occurs in 3–12%.

The pathogenesis for renal failure is multifactorial. One cause is the amount of light chain components of immunoglobulin leading to proximal tubular damage. Patients with Bence Jones myeloma (light chains only) are especially prone to this complication.

Other factors are dehydration, hypercalcemia, elevated uric acid, infections, and nephrotoxic medications.

More rare causes are amyloidosis, light chain precipitates, or plasma cell infiltration.

Prevention of renal failure

  • Renal function should be maintained by adequate fluid intake. 
  • The patient should obtain thorough information about the importance of monitoring renal function.
  • Patients should be careful in use of nephrotoxic medications including aminoglycosides, RAS-inhibitors and NSAIDs.

Hypercalcemia

Destruction of bone tissue associated with tumor growth can lead to elevated calcium levels in the blood.

Hypercalcemia, symptomatic or asymptomatic, occurs in up to 30% of multiple myeloma patients and usually when the disease is active (new or progressing). Quick diagnosis and treatment are very important. Symptoms which may indicate hypercalcemia are nausea/vomiting, constipation, thirst, polyuria, depression, and coma.

The threshold for further diagnostics must be low.

Recommendations for hypercalcemia
Grade Treatment
Mild hypercalcemia (calcium level 2.6–2.9 mmol/l) Oral rehydration
Moderate to severe hypercalcemia (³ 2.9 mmol/l) Intravenous rehydration, possibly furosemide

If the patient is not already receiving bisphosphonates, treatment should be initiated.

If the patient is taking bisphosphonates, starting a more potent medication or increasing the dosage may be appropriate.

Additional treatment may be necessary in patients with refractory disease.

Osteolytic lesions

All patients with myeloma benefit from and should have bisphosphonate treatment. This is given once a month and helps prevent development of new lesions. In Norway, this treatment is usually given for 2 years.

Osteonecrosis of the jaw is a feared side effect which can occur after long-term bisphosphonate treatment (most often > 2 years). To avoid this, it is important that patients are carefully examined by a dentist before starting this type of treatment. A dentist must approve start-up of the treatment.

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