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:
- Renal failure
- Osteolytic lesions
- Pain and fractures
- Clonal markers
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. Be sure not to miss other causes of anemia.
Patients generally have a reduced concentration of normal immunoglobulines and are often treated with corticosteroids and, in periods, may have severe neutropenia from chemotherapy. These patients are therefore more prone to infection and must be followed according to this.
Certain patients with recurring infections may benefit from substitution treatment with gammaglobulin. Indications for this type of treatment should be identified by a specialist. Proteasominhibitors also increase the risk of viral infections such as herpes zoster, and prophylactic antiviral treatment should be used.
Renal failure is observed in about 30% of patients, and in most patients, the kidneys are somewhat affected by the disease.
Severe 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 (normal) fluid intake.
- Renal function should be followed regularly.
- Patients should be careful in use of nephrotoxic medications including aminoglycosides, RAS-inhibitors, diuretics and NSAIDs.
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
|Mild hypercalcemia (calcium level 2.6–2.9 mmol/l)
|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.
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 of 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.