The build up of myeloma proteins in the bone marrow can cause a number of medical problems.
It is important that such problems be identified, monitored and treated.
Healthy bones are continually breaking down (referred to as resorption) so new bone can be laid down. There are two types of cells that are important for bone:
Myeloma cells stimulate the osteoclasts – the cells that break bone down – while inhibiting the osteoblasts, the cells that lay down new bone. If there is more bone breakdown than creation, there can be: 1) areas of damage or “holes” in the bone known as osteolytic or lytic lesions or 2) progressive bone thinning, called osteoporosis.
When bone thins or there are lytic lesions: You are at increased risk of fractures. Sometimes, even everyday activities can cause bones to break. Myeloma patients with bone disease can experience fractures in the ribs or compression fractures of the vertebrae in the spine. You may experience bone pain. The majority of myeloma patients experience bone pain at some point. Words commonly used to describe bone pain in myeloma include “constant,” “aching,” “deep” and “sharp.” The pain is often localized and worse when you move or shift positions. Compression fractures of the vertebrae can occur, which in turn can cause nerve damage and pain. What is done for bone disease in myeloma? Skeletal X-rays and bone density tests (a form of special X-ray ) are used to monitor bone loss and to check for specific areas of damage. People with myeloma are routinely prescribed bisphosphonate drugs that strengthen the bone, such as pamidronate (Aredia®) or zoledronic acid (Zometa®). Radiation therapy can be used to treat specific bone lesions and help relieve pain. Extensive radiation of the spine or the long bones should be avoided, however, as it can lead to prolonged suppression of the bone marrow. Vertebral fractures (fractures in the spine) have traditionally been treated by a procedure called vertebroplasty, in which cement is injected into the affected vertebrae to stabilize it. A newer alternative is kyphoplasty. In kyphoplasty, a balloon is inserted into the compressed vertebra and inflated to raise up the collapsed section. The cavity is then filled with a bone cement, stabilizing the vertebrae and preserving the reestablished height.
Is exercise safe? Unless there are reasons why you can not exercise, mild to moderate exercise such as walking or swimming may be physically and emotionally beneficial. It is important to avoid contact sports or activities that could result in falls. Talk with a physical therapist or your healthcare team about activities that would be suitable for you.
return to top
By crowding the bone marrow, myeloma can result in a reduced red blood cell count. Red blood cells are important because they contain hemoglobin. Hemoglobin carries oxygen from the lungs to the cells of your body, giving you energy and stamina. If the hemoglobin count is less than 120 g/L in a women or less than 133 g/L in a man, it is called anemia. Whether anemia requires treatment will depend upon its level, how quickly the level is changing, and how well you are feeling and functioning.
Symptoms of anemia include: feeling very tired even though you are getting enough rest looking pale becoming short of breath after even mild exertion finding it hard to do daily chores, to concentrate or to remember things feeling lightheaded or dizzy some people also report headaches, leg pains or feeling cold. Treatment options: If your anemia is due to a change in your diet, eating a healthier diet or taking iron, vitamin B12 or folic acid (folate) supplements. Always check with your doctor or pharmacist before taking any non-prescription, over-the-counter iron or vitamin supplement, or any herbal remedy. Some supplements or remedies can interact with prescription medications. Blood transfusions can be used to treat severe anemia and can quickly increase the hemoglobin level on a short-term basis. A medication can be prescribed that stimulates the body to make more red blood cells. Epoetin alfa (Eprex®) and Darbepoetin alfa (Aranesp®) contain versions of the human hormone erythropoietin, which tells the bone marrow to make more red blood cells. Both drugs are given by subcutaneous injection (an injection just under the skin).
Why treat anemia? Studies have shown that in people with cancer, treating anemia can help to relieve fatigue, make it easier to do everyday activities, reduce the need for blood transfusion, improve the quality of daily life and make it more likely they will be able to complete their cancer therapy. There are a number of treatment options for anemia, and it is important to discuss all of them with your healthcare team.
Myeloma and some of its treatments can affect the normal production of antibodies and reduce the white blood cell counts. This can leave a person susceptible to infections. Someone with this problem may get repeated infections or illness, especially respiratory infections, or take a long time to recover from them.
Many infections cannot be prevented, so it is important that they be treated as soon as they develop. Fever or other signs of infection or disease should be reported promptly to your health care team as antibiotics may be required. Also, because of the increased risk of infection, myeloma patients may require antibiotics before any dental work. It is important to have a complete dental examination before you begin any treatment therapy.
Reduce your risk: To reduce the risk of infections and illnesses, remember to practice good hand-washing techniques. When in public places, wash your hands frequently or use a hand sanitizer (the small containers can easily fit into your pocket or purse). Avoid situations where you may come into contact with people who are ill.
The M-proteins produced by myeloma are cleared from the body in the kidneys. Over time, the elevated levels of abnormal M-proteins in the blood and urine can damage the kidneys. This is why renal function is assessed regularly by creatinine testing of the blood.
The best way of preventing kidney damage (renal disease) is to treat the myeloma and keep the M-protein levels as low as possible. Sometimes – but infrequently – if the renal dysfunction is severe, dialysis may be required.
Drink up! Drinking lots of fluids can help to flush medications and toxins from your body, maintain normal blood volume and pressure, lubricate the joints, limit fatigue, and help to prevent kidney damage. The best single fluid to drink is water. Gradually increase your intake until you are drinking 2 litres of water a day. Try to limit drinks that contain caffeine, such as coffee, tea and soft drinks. Caffeine and alcohol increase your urine output and can lead to dehydration and fatigue.
As bone is broken down, it releases calcium into the blood stream. If the myeloma is causing a lot of bone damage, the blood can develop excessively high levels of calcium. This condition is called hypercalcemia. Hypercalcemia is a complication of myeloma and is treatable. Symptoms can include constipation, increased frequency of urination, weakness and in extreme cases, confusion.
Hold off on calcium supplements. In people without myeloma, calcium supplements are often recommended for bone health. But if you have myeloma, never take a calcium supplement without checking with your doctor. Too much calcium in the blood can be unhealthy.
Myeloma can result in other complications of the blood, although most are relatively rare. If the number of platelets in the blood drops below a healthy level, normal clotting will be affected. This can lead to bruising or excessive bleeding.
Some medications, such as thalidomide and lenalidomide (Revlimid®) can also increase the risk of blood clots in the veins, such as in the legs. Known as deep vein thrombosis (DVT), this can be a potentially dangerous complication. Blood thinning medications can be prescribed to reduce this risk.
In a small number of people, a high M-protein level can cause the blood to thicken (known as hyperviscosity). If this occurs, blood flow to the skin, fingers, toes, nose, kidneys or brain can be affected.
There are three main causes of pain for myeloma patients:
The sort of treatment you require will depend upon the cause of the pain, its severity, and how you respond to different therapies. Other treatments may be helpful. For example, bone pain may be relieved by radiation or bisphosphonates, and nerve damage due to compression fractures by vertebroplasty or kyphoplasty.
There are three broad categories of pain medications: Weak opioids, such as codeine, Percocet®/Percodan® and Oxycet® Non-steroidal anti-inflammatory drugs (NSAIDs), which include non-prescription medications such as acetylsalicylic acid (ASA, Aspirin®), ibuprofen (Motrin®, Advil®) and prescription medications such as the COX II inhibitors (Celebrex®, Mobicox®). NSAIDs can increase the risk of kidney damage and are usually not encouraged for routine use. Stronger opioids, which come in short-acting forms (meperidine or Demerol®), slow-acting forms (MSContin®, OxyContin®) or patches As always, each individual situation should be discussed with your doctor to evaluate the best treatment options. It may take some time to find the right treatment for your pain. Extreme cases may require treatment by a pain specialist.
As always, each individual situation should be discussed with your doctor to evaluate the best treatment options. It may take some time to find the right treatment for your pain. Extreme cases may require treatment by a pain specialist.
Pain medication dependency & addiction: Some myeloma patients hesitate to take opioid medications because they are afraid of addiction. Most health care professional agree that in someone with no history of dependency or addictions, there is little chance of developing a true addiction. Physical and psychological dependency can occur and can be handled by decreasing the dose gradually.
Peripheral neuropathy appears to be a side-effect of certain drugs used to treat myeloma, such as thalidomide, bortezomib (Velcade®) and vincristine. It usually occurs in the feet, legs, hands or arms and is very different from bone pain. These sensations may come on spontaneously without movement or get worse at night. Characteristics of neuropathic pain include:
Drug-induced neuropathy must be treated differently from bone pain or nerve damage resulting from spinal compression. First, it may be necessary to stop or reduce the drug causing the neuropathy. Second, the sorts of medications used for neuropathic pain are different. Drugs used to treat neuropathic pain include:
A number of unconventional and alternative approaches have been proposed for treating neuropathy but to date there is no evidence that they are effective.
Dental health is very important for myeloma patients. Encourage your dentist to talk with your oncologist to discuss any special precautions you may require, especially when receiving treatment. Check to see if your cancer centre has a dental clinic. Before starting any therapy, have a complete dental examination. Also, because of the increased risk of infection, myeloma patients may require antibiotics before any dental work.
Osteonecrosis of the jaw (ONJ) is a relatively rare side-effect of long-term bisphosphonate use in which there is abnormal death (necrosis) of the jaw bone. A review of patients at one of Canada’s largest myeloma centres, the Princess Margaret Hospital in Toronto, found that two percent of patients taking pamidronate developed osteonecrosis. It can occur spontaneously but appears to be more likely following dental work, particularly traumatic work such as extractions. The risk of osteonecrosis appears to be higher among those taking zoledronic acid (Zometa®), compared to pamidronate (Aredia®).
If you think you may take bisphosphonates in the future, be sure to have a complete dental examination all corrective work completed. Once you start taking bisphosphonates, it is recommended that you:
Restorative work such as fillings, bridges and crown and root canals are probably safe, provided wounds are as small as possible and all rough edges are carefully smoothed.
To reduce the risk of osteonecrosis of the jaw, many cancer centres are changing the way they prescribe bisphosphonates, either reducing the dose or the length of time for which they are taken.
All prescription medications have intended effects and others that you may not want, commonly known as side effects. Your healthcare team, particularly your pharmacist and nurse educator, can explain what side effects you can expect from the medications you are prescribed, which ones to report right away, and what can be done to relieve them.
Common side effects of chemotherapy are: Nausea and vomiting – anti-sickness (anti-emetic) drugs can help to prevent and control nausea and vomiting. Avoiding strong smells and getting lots of fresh air may also help. Vomiting can dehydrate you, so it is important to try and keep taking sips of cool drinks. Hair loss (alopecia) is common with some -- but not all -- kinds of chemotherapy. If it occurs, remember that your hair will grow back once your treatment has finished. Changes in the mouth – depending upon the type of chemotherapy you are receiving, you may experience mouth sores, or a sore or dry mouth. Medicines or a special mouthwash can help to prevent or treat mouth ulcers. When undergoing high dose intravenous chemotherapy (e.g., with melphalan), sucking on ice chips may help to prevent mouth sores. Keep your teeth clean by regularly using a soft toothbrush, and try to avoid things that might irritate your mouth, such as spicy, salty or tangy foods. If you have a sore or dry mouth, avoid food that sticks to the roof of your mouth (e.g., peanut butter or chocolate) and mouthwashes that contain alcohol. Moisten your food with gravy or sauces and try drinking through a straw or sucking ice-cubes or frozen treats. Loss of appetite – at times over the course of your treatment, you may have no appetite or feel you cannot face food. To avoid losing weight, try to eat small amounts of food – particularly fresh fruits and vegetables – frequently throughout the day. Or if you feel hungry at some parts of the day and not at others, eat your larger meal when you are hungry. No matter what you eat, be sure to always drink plenty of fluids. Side effect of corticosteroids (steroids) such as dexamethasone and prednisone, which are frequently used to treat myeloma, can include: fluid retention and swelling, particularly if you also have congestive heart failure an increase in blood sugar, which is of concern to people with diabetes or at risk of diabetes insomnia increased appetite indigestion or heartburn – speak to your physician about medication to prevent this problem hiccups blurred vision mood or emotional charges, such as depression, mood swings, agitation, anxiety, or even psychosis. Other effects than can develop after long-term use of high dose steroids include the Cushingoid appearance (weight gain with a “moon face”), osteoporosis or bone loss, and muscle weakness and/or wasting. Fatigue, depression and cataracts are other potential side effects.
Other effects than can develop after long-term use of high dose steroids include the Cushingoid appearance (weight gain with a “moon face”), osteoporosis or bone loss, and muscle weakness and/or wasting. Fatigue, depression and cataracts are other potential side effects.
Coping with “‘Roid Rage” Dealing with the diagnosis of cancer is hard – for you and your loved ones. The mood changes brought about by steroids can add to that burden. It is important that you talk with your loved ones and explain the effects steroids can have on your mood and activity levels. Give them a “heads up” when you will be going on and off your medication. Family members and friends can help by being supportive and understanding that sometimes “it’s the ‘roids talking”.
Some studies suggest that up to 40% of cancer patients experience depression or anxiety. As you deal with your disease, periods of feeling “blue” or “down” are not unusual. After all, you are going through a lot of changes. You may sometimes feel that you are no longer the person you used to be. Physical and mental changes may threaten your feeling of self-esteem.
Speak with a health professional if you experience five or more of the following symptoms for more than two weeks.
If the depression lasts for many weeks without relief or is severe enough to interfere with everyday life, you may need some help. Talk about your feelings with your doctor, nurse or counsellor. Sometimes just talking with someone is enough to help. In other cases, medication can be given to help relieve depression.
Many vitamins, supplements and herbal therapies can interact with your cancer medications.
Before taking any vitamin, supplement or herbal therapy, talk with your physician and/or your pharmacist.
Get the PDF version of the myeloma handbook by clicking here...
Myeloma Canada is affiliated with the International Myeloma Foundation, the world's oldest and largest myeloma organization
Myeloma Canada gratefully acknowledges the generous unrestricted educational grants from our website sponsors:
