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Suggest treatment for multiple myeloma

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Posted on Fri, 28 Nov 2014
Question: I was diagnosed in 2007 with Multiple Myeloma, was treated with IV Velcade, Revlimid initially then had ASCT with high dose Mephalan. Remission until Oct 2010, then started Revlimid with the dose gradually increasing to 25 mg, along with Dexamethasone 40 mg once a week. My blood counts have been steadily decreasing for the past 8-9 months, when Hgb got below 8, the Revlimid was discontinued (August 2014). Counts did not rebound as expected off the Revlimid, bone marrow bx in Oct showed myelodysplastic syndrome. IgA is up to about 420 now, so the MM is active. Tell me where to go next. We have appt next week with Dr. XXXXXXX Carrum at XXXXXXX Methodist.
doctor
Answered by Dr. Suresh Heijebu (2 hours later)
Brief Answer:
HLA matched BMT is definitive treatment.

Detailed Answer:
Hi Sir,

I read your query and understand your concern.

MM in your case has transformed into MDS/myelodysplastic syndrome.

You need to now consult expert Hematologist.

Many of the treatments are supportive and limited to clinical trials.

Blood counts can be improved by RBC,and platelet infusion.

Colony stimulating factors like GM-CSF are used to boost immunity.

Revalimid is effective against MDS,so its use can be continued.

The definitive treatment includes HLA-matched Bone Marrow Transplantation /BMT especially in early MDS.

Referral to tertiary care centers and participation in clinical trials is encouraged to acquire optimum new therapies at this stage.

Thank you.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Suresh Heijebu (1 hour later)
I was expecting an answer from an expert in this field, not a family practitioner. None of his information is new to us, and he disagrees with two leading oncologists who have said I should NEVER take Revlimid again. Sorry, but not worth $18.
doctor
Answered by Dr. Suresh Heijebu (14 hours later)
Brief Answer:
Revlimid is an US FDA approved for MDS.

Detailed Answer:
Hi Sir,

Just have gone through your concern.

Let me clarify certain things to you.

You are expecting an increase in blood counts to normal levels after stopping Revlimid,since you might be of the view that,these dropped cell counts are drug induced or whatever you might have thought.

MDS is characterised by hypercellular or hypocellular bone marrow with impaired morphology and maturation(dyserythropoiesis) and peripheral blood cytopenias,resulting from ineffective blood cell production.
All 3 cell counts would drop drastically and all of a sudden.

This MDS is literally known to eat away the stem cells of the bone marrow and it can develop all of a sudden in a patient with known clonal hematological disorder like MM being treated with cytotoxic chemotherapy like melphalan.

The origin of MDS in your case is most likely due to 3 possible factors-
1.Therapy related to cytotoxic chemotherapy used for MM.
2.Acquired new genetic mutations from long standing,relapsed forms of MM.
3.ASCT pretreated individuals can develop Secondary MDS in few cases.

These changes are evident in your case since past 9 months,which probably explains the sudden onset of MDS.

Revlimid, is known to cause mainly thrombocytopenia/low platelet count and neutropenia in just about 10% individuals within 4 weeks of onset of therapy.

You seem to have used Revlimid initially in 2007, ,later again after 2010 before discontinuing it.

Hence in your case Revlimid is not the culprit for low blood counts.

Revlimid is now a an approved drug for MDS by the US FDA at doses of 10mg/ day in all patients keeping a watchful eye on the platelet counts as to reschedule the dose to 5 mg/day in patients who have more than 50% drop in their baseline platelet count after the initiation of therapy,if necessary.


Hence i do not find the reason for discontinuation of Revlimid in your case,especially when its quite capable of controlling both MM and MDS progression.

My answer to you is based on the line of "tell me where to go next" in your query.

I am unsure of what new info you are looking for.

The treatment options in case of MDS are very limited.
These are the only possible therapeutic guidelines to existing to treat your MM with MDS in my opinion.

You also have the option of consulting a specialist Oncologist on this health portal to directly answer your query, if you are quite dissatisfied with my answer.

My best wishes to you.
Take care.
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
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Answered by
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Dr. Suresh Heijebu

General & Family Physician

Practicing since :2010

Answered : 3659 Questions

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Suggest treatment for multiple myeloma

Brief Answer: HLA matched BMT is definitive treatment. Detailed Answer: Hi Sir, I read your query and understand your concern. MM in your case has transformed into MDS/myelodysplastic syndrome. You need to now consult expert Hematologist. Many of the treatments are supportive and limited to clinical trials. Blood counts can be improved by RBC,and platelet infusion. Colony stimulating factors like GM-CSF are used to boost immunity. Revalimid is effective against MDS,so its use can be continued. The definitive treatment includes HLA-matched Bone Marrow Transplantation /BMT especially in early MDS. Referral to tertiary care centers and participation in clinical trials is encouraged to acquire optimum new therapies at this stage. Thank you.