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Management of multiple myeloma in resource-poor settings

Author
S Vincent Rajkumar, MD
Section Editor
Robert A Kyle, MD
Deputy Editor
Rebecca F Connor, MD

INTRODUCTION

Multiple myeloma (MM) is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin. MM is distinguished from premalignant plasma cell dyscrasias, namely monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), by the presence of organ dysfunction (anemia, hypercalcemia, renal insufficiency, infection, and skeletal lesions) attributed to the malignant clone. Patients with MM are given therapies directed at the underlying plasma cell clone with the goal of preventing further complications. In contrast, active treatment is not routinely indicated for patients with MGUS or SMM. (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma".)

High dose chemotherapy followed by autologous hematopoietic cell transplantation (HCT, rescue) is considered a standard of care for eligible patients with newly diagnosed MM. However, access to autologous HCT is limited in certain areas of the world by age restrictions or resource limitations. In a similar vein, while initial therapy has shifted towards using immunomodulatory drugs (eg, lenalidomide) and proteasome inhibitors (eg, bortezomib) as initial therapy, these drugs may not be available in resource-poor settings.

The selection of initial treatment regimen for patients with MM in resource-poor settings is discussed here. The general approach to therapy of MM, including diagnostic evaluation, risk stratification, details regarding the use and timing of autologous HCT, and the response evaluation, is presented separately, as is the selection of initial treatment for patients with MM in other settings. (See "Overview of the management of multiple myeloma" and "Selection of initial chemotherapy for symptomatic multiple myeloma".)

Discussions of relapsed or resistant MM, the treatment of complications of MM (eg, hypercalcemia, renal insufficiency, skeletal lesions), and the use of bisphosphonates are presented separately. (See "Treatment of relapsed or refractory multiple myeloma" and "Treatment of the complications of multiple myeloma" and "The use of bisphosphonates in patients with multiple myeloma".)

THE RESOURCE-POOR SETTING

Limitations to care — The treatment of patients with MM in much of the world has shifted away from the routine use of alkylator-based combinations such as melphalan and prednisone (MP) and towards a risk-stratified approach with the early incorporation of immunomodulatory drugs (eg, lenalidomide) and proteasome inhibitors (eg, bortezomib). In addition, high dose chemotherapy followed by autologous hematopoietic cell transplantation (HCT, rescue) is considered a standard of care for eligible patients with newly diagnosed MM. However, access to autologous HCT and novel agents is limited in certain areas of the world by age restrictions or resource limitations. Patients in such settings can still benefit from the use of treatment regimens that are based on alkylating agents (eg, melphalan) and/or first generation immunomodulatory agents (eg, thalidomide). Details regarding the use of these regimens and guidance regarding the choice of regimen are provided in the following sections. More modern regimens are presented separately. (See "Selection of initial chemotherapy for symptomatic multiple myeloma".)

                

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Literature review current through: Nov 2016. | This topic last updated: Thu Mar 10 00:00:00 GMT+00:00 2016.
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