As new therapies come to market, patients with multiple myeloma (MM) have more treatment options that are improving outcomes and extending overall survival. However, the most effective options involve multidrug combinations and continuous maintenance therapy, which can result in cumulative toxicities and the potential for oncologic emergencies (OEs).
The Clinical Journal of Oncology Nursing published a supplement to its October 2017 issue that discussed treatment and symptom management options for patients with MM, including an overview of evidence-based recommendations for key OEs: myelosuppression, bone disease, and acute renal failure.
Anemia, neutropenia, and thrombocytopenia can all occur with myelosuppression from treatment with immunomodulatory agents, proteasome inhibitors, or monocolonal antibodies. “If severe, consequences of under-recognized or untreated myelosuppression can lead to OEs such as life-threatening anemia, neutropenic fever, or bleeding from thrombocytopenia.”
Anemia: About 97% of patients with MM develop anemia at some point during their disease, and about 8% have severe anemia. The condition may reduce survival and affect outcomes and quality of life. The risk is highest among patients who are undergoing platinum-based chemotherapy.
In MM, anemia usually results from myeloma cells inducing the death of erythroblasts, which are needed to make red blood cells. Cytokines can also sequester iron from red blood cells. Signs and symptoms of anemia include pallor of the skin and mucous membranes, shortness of breath, heart palpitations, soft systolic murmurs, lethargy, and fatigue.
Neutropenia: Even mild neutropenia can result in OE in patients with MM as disease progresses and immune dysfunction worsens. Because the newer MM treatments are often used in combination with corticosteroids, which are highly immunosuppressive, patients are at increased risk for infection.
Fever may be the first and only sign of infection in profoundly neutropenic patients. Other symptoms include chills, rigors, cough, dyspnea, nausea, diarrhea, dysuria, dizziness, fatigue, and pain.
Thrombocytopenia: In patients with MM, thrombocytopenia is often present at diagnosis but becomes most severe at end-stage disease. Severe thrombocytopenia is considered a life-threatening OE. It also commonly occurs with proteasome inhibitor treatment, where it is typically cyclical, predictable, and reversible. Additionally, Brigle et al. noted that patients receiving immunomodulatory agents or carfilzomib should also take antithrombotic agents, which reduces their risk of thrombotic events but increases their risk of bleeding. Treatment-related thrombocytopenia usually develops gradually, but it can appear rapidly when related to viral or bacterial infections.
Signs and symptoms include ecchymosis, petechiae, epistaxis, hemoptysis, hematuria, hematemesis, melena, vaginal bleeding, or oozing from skin lesions or vascular access lines. Catastrophic hemorrhage may occur, such as a major cerebral or gastrointestinal bleed.
About 90% of patients with MM will have lytic lesions at some point during the disease process. At diagnosis, about 80% of patients have bone disease and 60% present with bone pain.
Hypercalcemia of malignancy (HOM): Because of the high incidence of bone disease in MM, HOM is a potential OE that oncology nurses should be aware of. About 15%–40% of patients with MM present with HOM during the disease process, and about 20% of newly diagnosed patients with MM will present with a calcium level less than 10.5 mg/dl. If HOM is treated, it has a reverse rate of 80%, but if untreated it can result in renal failure and death.
Signs and symptoms include lethargy, constipation, dysuria, polydipsia, confusion, muscle weakness, and cardiac dysrhythmias. The primary focus of treatment should be to reduce serum calcium quickly and safely, then identify and treat the underlying cause of HOM. Because HOM usually indicates active or relapsed disease, additional diagnostic testing and disease reassessment should occur.
Spinal cord compression (SCC): About 50% of patients with bone disease will have spinal involvement; 30% of those will have vertebral compression fracture, and less than 5% will have SCC. However, MM is involved in 11% of SCC complications. In MM, SCC can result from lesions involving the vertebrae or extra-osseous plasmacytoma, both of which compromise the spinal cord and cause back pain that progresses to neurologic deficit if untreated.
Signs and symptoms are back pain and neurologic symptoms, including weakness and paresthesia extending from the abdomen to the lower extremities; bladder, bowel, and sexual dysfunction; and paralysis. Upper-body weakness or paresthesia, respiratory insufficiency, and Lhermitte sign or Horner syndrome indicate a higher level of spinal involvement.
“SCC is an OE requiring immediate intervention to prevent progression of symptoms and nerve damage.”
Acute Renal Failure
Any rapid decline in renal function should be considered an OE in patients with active MM, Brigle et al. noted. It can result from many factors, including active infections, dehydration, use of nephrotoxic medications, comorbidities (e.g., uncontrolled diabetes or hypertension). In MM, dehydration can cause acute tubular necrosis that results in acute renal failure, and HOM can lead to vasoconstriction in the kidneys. See Figure 1 for a list of health conditions, drugs, and risk factors for acute renal failure in patients with MM.
To prevent acute renal failure, patients should avoid nephrotoxic agents such as nonsteroidal anti-inflammatory drugs and maintain adequate hydration. Oncology nurses should assess oral hydration intake at every appointment, encourage patients to drink plenty of hydrating fluids, and instruct them to avoid excessive amounts of caffeine.
Quickly address acute renal failure with hyperhydration, but closely monitor patients for fluid volume overload. Controlling the condition quickly gives the kidneys the best chance of recovery.
Evidence-Based Strategies to Manage OEs
Brigle et al. provided a comprehensive, detailed list of evidence-based recommendations for prevention and management of the OEs listed here. They are organized by level of evidence, so oncology nurses can quickly understand which interventions have the most support. For the complete list of recommendations, refer to the full article by Brigle et al.
This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes the multiple myeloma supplement to the October 2017 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.