What Medications Treat Myeloma?
Numerous chemotherapy and biological drug combinations have been used for multiple myeloma. Which type and combination of therapy depends on many factors, including the type and stage of myeloma, the ability to tolerate chemotherapy side effects, and if any previous treatment was rendered or if further treatment is planned, such as stem cell transplantation.
Hematologists/oncologists often work together regionally to decide which combination of chemotherapy and biological drugs are currently working best for their patients. Because of this regional collaboration, the drug combinations often vary and are able to change rapidly when improved results occur.
- Combinations of different chemotherapy drugs seem to be more effective than single agents. Several drugs with different mechanisms of action, when given together at lower doses, will likely increase the effectiveness of treatment, while reducing the likelihood of intolerable side effects.
- Several different standard combinations are used as induction therapy in myeloma; today combinations frequently considered involve an immunomodulatory drug such as thalidomide or lenalidomide in combination with dexamethasone.
- Combinations involving bortezomib (Velcade) are also increasingly frequently considered. Newer drugs in the family of bortezomib with activity against myeloma include carfilzomib (Kyprolis) and ixazomib (Ninlaro).
- Older combinations included the combination of vincristine (Oncovin), doxorubicin (Adriamycin), and the corticosteroid, dexamethasone (Decadron). This combination of drugs is referred to as "VAD." Still an older combination is melphalan plus prednisone.
- Which combination a person is given depends on the treatment plan and the experiences of the specialist and the medical center where treatment is received. For example, if a stem cell transplant is part of a treatment plan, melphalan may not be given, since it can reduce stem cell production and impair the ability to then harvest such cells before a transplant is planned.
- The combinations of drugs are usually given according to a set schedule that must be followed strictly.
- In most situations the treatments can be given in or through the oncologist's office. If a patient is too ill with symptoms of multiple myeloma the treatment may be given in the hospital.
Chemotherapy is given in cycles.
- One cycle includes the period of actual treatment (usually several days) followed by a period of rest and recovery (usually a few weeks).
- Standard treatment typically includes a set number of cycles, such as four or six. Spacing out the chemotherapy this way allows a higher cumulative dose to be given while improving the person's ability to tolerate the side effects.
Chemotherapy may be given in pill form or in liquid form to be infused directly into the bloodstream through a vein (intravenous).
- Certain drugs widely used against myeloma, namely melphalan, prednisone, dexamethasone, as well as thalidomide and lenalidomide, and ixazomib, are given in pill form.
- Most people who receive intravenous (IV) chemotherapy will have a semi-permanent device placed in a vein, usually in the chest or upper arm. This device allows a person's medical team quick and easy access to blood vessels, both for administering medications and for collecting blood samples. These devices come in several types, usually referred to as "catheter," "port," or "central line." These devices can be easily lived with at home, and require varying types of care depending on the device used.
Bisphosphonates: All patients receiving primary therapy for multiple myeloma should receive bisphosphonates. Those in most common use are pamidronate (Aredia) and zoledronic acid (Zometa). These are not chemotherapy agents, but can reduce the frequency of symptomatic skeletal events such as fractures. They can also treat hypercalcemia.
Other Drugs: Other drugs that are standard treatments for myeloma are corticosteroids (prednisone or dexamethasone) and thalidomide (Thalomid) and lenalidomide (Revlimid).
Corticosteroids are powerful drugs that have many different actions, including anti-inflammatory and anti-immunity activity. They are active against myeloma and reduce production of the M protein. Prednisone and dexamethasone can be given with chemotherapy agents or alone for people who cannot tolerate chemotherapy drugs or need them to help to lower calcium levels or to reduce swelling around nerves being pressed upon by masses of plasma cells in or next to bones.
Immune system modifying drugs such as thalidomide or lenalidomide are not chemotherapy agents in the traditional sense. These immunomodulatory agents are usually given with a corticosteroid, such as dexamethasone (Decadron). Thalidomide's actions may include decreasing the ability of cancer spread throughout the blood (antiangiogenesis), interfering with adhesion molecules, or enhancing release of cytokines (cancer-fighting substances within the body).
This drug may be associated with sleepiness, constipation, venous blood clots, and numbness and tingling in the tips of the extremities. It is absolutely contraindicated in pregnancy, as it causes birth defects. The drug is dispensed through a program that ensures that physicians have educated patients about the importance of contraception when taking the drug. Usually, aspirin or low-dose blood thinners, such as warfarin (Coumadin) are given in conjunction with thalidomide and corticosteroids.
New Drug Therapy
- An analogue of thalidomide, CC-5013, or lenalidomide (Revlimid), purportedly has fewer side effects of thalidomide and appears to be more potent than thalidomide in laboratory studies. It is also an immunomodulatory agent. It has been evaluated as part of combined therapy with corticosteroids or chemotherapy drugs. The combination of lenalidomide and a corticosteroid is now FDA-approved as a first-line treatment option in multiple myeloma. Currently, other immunomodulatory drugs for myeloma are also undergoing development.
- Bortezomib (Velcade) is the first of a new class of medicines called proteasome inhibitors (bortezomib-based therapy). Proteasome inhibitors may preferentially disrupt a cancer cell's growth. Other proteasome inhibitors have recently been developed include carfilzomib and ixazomib.
- The patient's medical team should discuss the treatments and side effects with the patient; each patient is different, so the treatments may vary. Patients should discuss their treatments and ask their doctors about any concerns.