Myeloma and treatment of myeloma can lead to mild to serious health complications and side effects. Some of these symptoms can be managed with ongoing supportive (palliative) care. Others may be medical emergencies requiring immediate attention. Always tell your healthcare team if you experience new or worsening symptoms.
Pain related to myeloma or myeloma treatment can include
- Bone Pain. Bone pain may occur due to bone thinning and lesions caused by the growth of myeloma cells in the bones. Patients may also experience pain that radiates from the back when the back bones (vertebrae) collapse and press on the nerves. Fractures of bones may also result in pain. Successful treatment of the disease and its complications may relieve bone pain, but many patients may require pain medications, including narcotics.
- Peripheral Neuropathy. Temporary or ongoing numbness, tingling, burning, coldness or weakness in the arms or legs are symptoms of peripheral neuropathy, which occurs when the nerves to your peripheral nervous system are damaged. It can be a result of the disease, or it can be a side effect of certain anticancer drugs, including vincristine (Oncovin®), bortezomib (Velcade®), carfilzomib (Kyprolis®), thalidomide (Thalomid®), pomalidomide (Pomalyst®), and, less commonly, lenalidomide (Revlimid®). Let your doctor know immediately if you experience any symptoms common to peripheral neuropathy. He or she can adjust your medication to relieve the condition.
For more information, see Supportive Care.
Osteonecrosis of the Jaw
Patients who take bisphosphonates such as pamidronate (Aredia®) and zoledronic acid (Zometa®) may be susceptible to a type of jawbone damage called osteonecrosis of the jaw (ONJ). ONJ is rare. It occurs when bones in the jaw begin to break down and die. Symptoms include pain, swelling, poor healing or infection of the gums, loosening of teeth or numbness (or a feeling of heaviness) in the jaw. Before you begin any treatment with bisphosphonates, get any needed dental work completed and a dental exam. Your oncologist should coordinate closely with an oral surgeon or dental specialist to manage your bisphosphonate treatment. Treatment of ONJ may include frequent clinical assessments, antibiotics, oral rinses and removable mouth prostheses. Minor dental work may be necessary to remove injured tissue and reduce sharp edges of bone. Typically, surgery is avoided because it may make the ONJ worse, but it is needed and can be helpful in some cases.
Myeloma patients may have serious problems with kidney function for two principal reasons. One reason is the excretion of large amounts of monoclonal proteins in the urine. This excess protein can damage the kidney filtration apparatus and the channels or tubules that are important in urine formation. Another reason is that patients with myeloma often have high levels of calcium (hypercalcemia) or uric acid (hyperuricemia) in the blood. When bones are damaged, calcium is released into the blood. High levels of calcium in the blood cause dehydration that can damage the kidneys. If kidney function does not improve with myeloma treatment, patients may need dialysis.
In rare cases, when patients have very recent or acute kidney failure due to high levels of antibody proteins in the blood, a procedure known as “plasmapheresis and exchange” may be helpful in limiting kidney damage, though this approach is controversial. It provides temporary removal of proteins from the blood, which will accumulate again if the source of the problem (the myeloma) is not eliminated. The most important and successful treatment for kidney failure is to treat the myeloma itself.
Bone marrow is constantly producing red blood cells, white blood cells and platelets. Interruption or inhibition of this crucial function is called “myelosuppression.” Chemotherapy agents, immunomodulatory drugs such as lenalidomide (Revlimid®) and proteasome inhibitors such as bortezomib (Velcade®) can cause myelosuppression. If not managed effectively, myelosuppression can be life threatening and interfere with treatment planning and quality of life. Myelosuppression can cause
- Anemia (low red blood cells). Symptoms of anemia include fatigue, shortness of breath, pale skin, and dizziness.
- Neutropenia (low neutrophils, a type of white blood cell). Neutropenia can lead to serious infections that require antibiotic therapy and possibly hospitalization. Drugs, such as filgrastim (Neupogen®), pegfilgrastim (Neulasta®) or sargramostim (Leukine®), may be prescribed to treat neutropenia.
- Thrombocytopenia (low platelet counts). Patients who have low platelet counts may experience excessive bleeding from cuts or injuries and may need a platelet transfusion.
For information on managing anemai and preventing infection, see Supportive Care.
Thrombosis and Embolism
Deep venous thrombosis (DVT) occurs when a blot clot develops in a vein deep in your body, usually in the legs. DVT can cause pain and swelling in the affected limb. If the clot breaks away, it can travel to your lungs or pulmonary arteries and become a pulmonary (lung) embolism, which can be life threatening.
Myeloma patients risk developing DVT and pulmonary embolism as a result of treatment with drugs such as thalidomide (Thalomid) and lenalidomide (Revlimid) combined with corticosteroids like dexamethasone (Decadron®) and liposomal doxorubicin (Doxil®). Some doctors have observed that taking either Thalomid or Revlimid and dexamethasone in combination with red cell growth factors, for example epoetin alfa (Procrit®) or darbepoetin alfa (Aranesp®), further increases a patient’s risk for DVT. Other factors that can increase the risk of DVT include the presence of a central line (central venous catheter), decreased mobility, recent surgery, pregnancy, smoking, a prior history of DVT or a family history of blood-clotting problems.
Patients receiving myeloma treatment associated with DVT risk, especially newly diagnosed myeloma patients, are usually prescribed medication (such as aspirin, warfarin (Coumadin®), or low-molecular-weight heparin) to reduce the risk of DVT. It is important for patients to discuss with their doctors the risk of DVT and ask which of the options to reduce this risk is best for them.
Occasionally, the concentration of monoclonal proteins in the blood of some myeloma patients is so high that it makes the blood “viscous” (thick), thereby interfering with the blood flow and delivery of oxygen to the tissues. This condition is referred to as “hyperviscosity syndrome.” The circulation of the oxygen-carrying red blood cells slows down, and the work of the heart is increased by the difficulty of pumping blood through the body. Symptoms include headaches, dizziness, weakness, fatigue, sleepiness, and oozing from cuts.
Hyperviscosity syndrome is considered a medical emergency and requires urgent treatment with plasmapheresis and exchange. This procedure rapidly reduces the concentration of monoclonal proteins in the blood. Chemotherapy is needed as well to prevent the complication from occurring again.
Rarely, monoclonal IgM may congeal in the blood and lead to poor circulation, especially if the body is exposed to cold temperatures. This condition can cause joint pain, kidney problems, skin lesions and purpura (purplish or red-brown skin discoloration). Cryoglobulinemia is a rare condition.
Acute Myeloid Leukemia
Myeloma patients have an increased risk of developing acute myeloid leukemia (AML), especially after being treated with cytotoxic anticancer drugs. AML development, however, is a rare occurrence.