Treatment of multiple myeloma
Patients need serious maintenance treatment. Ambulatory maintenance therapy helps to maintain bone density. Analgesics and palliative doses of radiotherapy (18-24 Gy) can relieve pain in the bones. However, radiation therapy may interfere with the conduct of course chemotherapy. All patients should also receive bisphosphonates, which reduce the risk of developing complications from the skeleton, relieve bone pain and have antitumor activity.
Adequate hydration is the prevention of kidney damage. Even patients with prolonged, massive Bens-Jones proteinuria (10-30 g / day) can maintain kidney function if they maintain diuresis more than 2000 ml / day. In patients with Bence-Jones proteinuria, the dehydration accompanying the administration of a highly osmolar intravenous contrast may cause acute renal failure.
To treat hypercalcemia, abundant hydration and bisphosphonates are used, sometimes together with prednisolone 60-80 mg orally per day. Although most patients do not need to take allopurinol, taking 300 mg per day is indicated if there is kidney failure or symptoms of hyperuricemia.
Preventive vaccination against pneumococcal infection and influenza has been shown. The administration of antibiotics is performed with documented bacterial infection and the routine preventive administration of antibiotics is not recommended. Prophylactic administration of intravenous immunoglobulin can reduce the risk of infectious complications, usually prescribed to patients with frequent recurrent infections.
Recombinant erythropoietin (40,000 units subcutaneously 3 times a week) is used in patients with anemia that is not curable by chemotherapy. If anemia leads to violations from the cardiovascular system, transfusion of erythrocyte mass is used. With the development of hyperviscosity syndrome, plasmapheresis is performed. Conduction of chemotherapy is indicated to reduce serum or urinary M-protein. Post-cystostatic neutropenia can contribute to the development of infectious complications.
Standard chemotherapy usually consists of oral melphalan [0.15 mg / (kg x day)) and prednisolone (20 mg 3 times a day) every 6 weeks, with a response rate of 3-6 months. Polychemotherapy can be performed with the use of various regimes with intravenous administration of drugs. These regimens do not improve long-term survival compared to the combination of melphalan and prednisolone, but may provide a faster response in patients with renal dysfunction. Autologous transplantation of hematopoietic stem cells has been shown to patients younger than 70 years with an adequate function of the heart, liver, lungs and kidneys with a stable course of the disease or a good response after several courses of standard chemotherapy. These patients undergo initial chemotherapy with vincristine, doxorubicin and dexamethasone or dexamethasone with thalidomide. If it is necessary to prescribe a myeloid growth factor, drugs that inhibit bone marrow function, alkylating agents and nitrosoureas are not prescribed. Carrying out allogeneic transplantation with non-myeloablative regimens of conditioning (eg, low doses of cyclophosphamide and fludarabine or radiation therapy) in some patients can improve disease-free survival up to 5-10 years due to a decrease in toxicity and the presence of an immune allogeneic anti-myeloma effect. This method is indicated for patients younger than 55 years with a good physiological reserve. With relapse or refractory myeloma, new drugs (thalidomide, immunomodulatory drugs, proteasome inhibitors) are used, the effectiveness of these drugs as first-line therapy is being studied.
Supportive therapy is provided by non-chemotherapeutic drugs, including interferon, which provide a lasting effect, but have some side effects. The use of glucocorticoids as maintenance therapy is being studied.