preferably be involved to obtain a good dietary history and to advise on frequent meals and nutritional supplements.
Nausea and vomiting
Acute emesis may occur as a result of hypercalcaemia, analgesic side effects and toxicities of anticancer treatments. Most courses of therapy used in myeloma are not highly emetogenic. Nausea can usually be managed primarily with dopaminergic prokinetic anti-emetics. An anticholinergic drug, cyclizine, can be effective but can cause dry mouth and sedation. If emesis does not settle, then haloperidol is usually effective (1.5mg every night as a single oral or subcutaneous) and lastly, the broad- spectrum phenothiazine
levomepromazine may be used. Acute emesis induced by the more intensive chemotherapy regimens could be controlled using the serotonin (5-HT3
of opioid can be given by syringe driver. End-of-life care
In the majority of patients with MM, their disease is incurable and will shorten life. It is important to recognise when a patient has advancing disease with no further anti-myeloma treatment options and the likelihood of death occurring within 6–12 months. At this point, a discussion regarding referral to a palliative care team might be relevant to enable the team to become acquainted with the patient. Holistic needs assessments may be helpful in highlighting problems and issues alongside the symptoms, such as psychological and social difficulties, existing concerns and advance decisions
College of General Practitioners. Pain Med 2010;11(5):742–64.
4. Raphael J et al. Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. Pain Med 2010;11(6):872-96.
5. Richardson PG et al. Management of treatment- emergent peripheral neuropathy in multiple myeloma. Leukemia 2011;26:595–608.
6. Mohty B. Peripheral neuropathy and new treatments for multiple myeloma: background and practical recommendations. Haematologica 2010;95(2):311–19.
7. Bang SM et al. A multicenter retrospective analysis of adverse events in Korean patients using
receptor antagonists if the above medication fails. Intolerable nausea and vomiting may warrant treatment with the neurokinin-1 antagonist aprepitant.
Constipation and diarrhoea Constipation is common in myeloma patients and may be the result of adverse effects of drug therapy with thalidomide,
Therefore, a combination of a stool softener, such as docusate, together with a stimulant, such as senna or
opioids, anti-cholinergics or 5-HT3 receptor antagonists or hypercalcaemia. Laxative treatment is commonly used but there is not a strong evidence base for its use.15
codanthrusate, and a regular macrogol or lactulose might be considered for prevention of constipation. By contrast, lenalidomide and bortezomib can cause diarrhoea, which might require dose modification or discontinuation of the drug.16
underlying cause of the diarrhoea should be targeted, but symptomatic measures include the use of anti-motility agents and anti-cholinergic drugs.
Myeloma patients on chemotherapy frequently develop oropharyngeal mucositis especially during the neutropenic phase of HSCT. Mild grades of mucositis can be managed with weak analgesic and difflam mouthwashes whereas moderate cases can be managed with a combination of oxetacaine and antacid and lidocaine and ice lollies and, in severe cases, a subcutaneous infusion
“Optimal supportive and palliative care, in parallel with disease control, is necessary to maximise quality of life at all stages of the disease”
regarding future care. Every treatment given should be assessed to see if the benefits continue to outweigh the risks and burdens. In the last days of life, when the patient becomes increasingly bed-bound, is weak and has reduced levels of consciousness, the focus of attention of the team is on the patient’s main priorities and also looking after the family and carers.
Patients with MM are living longer but accumulating a burden of symptoms, so optimal supportive and palliative care is necessary in parallel with disease control to maximise quality of life at all stages of the disease. Collaboration with other relevant specialists, including palliative medicine, pain management, clinical oncologists and surgical specialties, is often essential. l
References 1. Brenner H, Gondos A, Pulte D. Expected long-term survival of patients diagnosed with multiple myeloma in 2006-2010. Haematologica 2009;94(2):270–5.
2. Snowden JA et al. Guidelines for supportive care in multiple myeloma 2011. Br J Haematol 2011;154(1):76–103.
3. Raphael J et al. Cancer pain: part 1: Pathophysiology; oncological, pharmacological, and psychological treatments: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal
bortezomib for multiple myeloma. Int J Hematol 2006;83(4):309–13.
8. Kyle RA et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003;78(1):21–33.
9. Locatelli F et al. Revised European best practice guidelines for the management of anaemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19 Suppl 2:ii1–47.
10. Srkalovic G et al. Monoclonal gammopathy of undetermined significance and multiple myeloma are associated with an increased incidence of venothromboembolic disease. Cancer 2004;101(3):558–66.
11. Carrier M. Rates of venous thromboembolism in multiple myeloma patients undergoing immunomodulatory therapy with thalidomide or lenalidomide: a systematic review and meta- analysis. J Thromb Haemost 2011;9(4):653–63.
12. Shafqat A et al. Screening studies for fatigue and laboratory correlates in cancer patients undergoing treatment. Ann Oncol 2005;16(9): 1545–50.
13. Minton O et al. Psychostimulants for the management of cancer-related fatigue: a systematic review and meta-analysis. J Pain Symptom Manage 2011;41(4):761–7.
14. Murray SM, Pindoria S. Nutrition support for bone marrow transplant patients. Cochrane Database Syst Rev 2009(1):CD002920.
15. Ahmedzai SH, Boland J. Constipation in people prescribed opioids. Clin Evid (Online) 2007;Jun 1:2407.
16. Bird JM et al. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol 2011;154(1):32–75.
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