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Based on BJGP2018;e586 & NICE 2018, NG35 & NICE-CKS 2016

  • Just remind me...
    • Myeloma is caused by a proliferation of monoclonal plasma cells in the bone marrow which secrete immunoglobulins, known as M proteins or paraproteins
    • These paraproteins increase plasma viscosity and cause renal damage, and the proliferation of plasma cells leads to bone marrow suppression and can cause hypercalcaemia
    • The median age of diagnosis is 70; only 15% of patients are aged under 60
    • The typical features of myeloma give rise to symptoms of fatigue, bone and MSK pains, headache, nausea, recurrent infections etc
    • Patients often present late with hypercalcaemia, pathological fractures or renal failure
    • Prognosis is variable, with survival times varying from a few weeks to 20 years; most respond to initial treatment and have a period of stability before relapse after 2 to 5 years; younger fitter patients who have high dose therapy and stem cell transplantation can expect to survive for a median of 7 years 
    • MGUS = monoclonal gammopathy of uncertain significance 
      • MGUS is a non-malignant condition with an abnormal paraprotein or M-protein
      • It is usually an asymptomatic, chance finding and once myeloma has been ruled out treatment is not necessary, however, patients have a chance of progression to myeloma or lymphoma at a rate of 1% per year with a latent period of up to 20 years
  • Diagnosis in primary care
    • Consider possible myeloma in adults (especially aged over 60) presenting with non-specific symptoms e.g. fatigue, bone pain, recurrent infection, headaches etc.
    • Check FBC, ESR, renal function and calcium studies in all patients
    • A normal FBC and ESR  is sufficient to rule out the disease in most patients presenting in primary care with non-specific symptoms
    • ESR is a better 'rule out' inflammatory marker for myeloma than CRP
    • If FBC, ESR, creatinine, or calcium are abnormal or if the index of suspicion is higher arrange urgent serum electrophoresis and Bence-Jones protein urine assessment
    • Serum electrophoresis and Bence-Jones protein are negative in 2% of people who have a non-secretory form of the disease, so refer if significant clinical suspicion persists
    • Arrange XRays of symptomatic areas of bone pain to exclude pathological fracture
    • Arrange urgent admission if significant hypercalcaemia or acute kidney injury
    • If serum and/or urine protein electrophoresis suggest myeloma urgent haematology referral
  • Secondary care management
    • Diagnostic confirmation is via further blood tests, bone marrow aspirate and biopsy and skeletal MRI
    • Secondary care management depends on disease stage, prognosis and co-morbidities but may include bisphosphonates, corticosteroids, chemotherapy and immune-modulating drugs
    • High dose chemotherapy and stem cell transplant may be offered in younger, fitter patients
  • Primary care management
    • On-going support and holistic care, including lifestyle advice e.g. maintaining good hydration status
    • Identification and prompt investigation of possible new complications, including: pathological fractures, spinal cord compression, impaired immunity, anaemia, bleeding disorders, acute kidney injury, cognitive impairment and stroke due to hyperviscosity
    • Prompt treatment of infections with broad-spectrum antibiotics
    • Vaccination, seasonal influenza and also pneumococcal
    • Pain control (avoid NSAIDs due to renal risk)
    • Management of depression and anxiety
    • Supportive and palliative care
Published on 27th November 2019

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