Treatment

Treatment for multiple myeloma can often help control symptoms and improve quality of life. But myeloma usually can't be cured, which means additional treatment is needed when the cancer comes back.

Not everyone diagnosed with myeloma needs immediate treatment – for example, the condition may not be causing any problems. This is sometimes referred to as asymptomatic or smouldering myeloma.

Find out more about smouldering myeloma on the Myeloma UK website

If you don't need treatment, you'll be monitored for signs the cancer is beginning to cause problems.

If you do need treatment, the most commonly used options are outlined below.

Discussing your multiple myeloma treatment

If you have multiple myeloma, you'll be cared for by a team, which is usually led by a consultant haematologist who specialises in myeloma.

The team will discuss your condition and recommend the best treatment for you. However, the final decision to begin treatment will be yours.

Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions to ask the specialist.

For example, you may want to find out the advantages and disadvantages of a particular treatment.

Bringing myeloma under control

The initial treatment for multiple myeloma may be either:

• non-intensive – for older or less fit patients (this is more common)
• intensive – for younger or fitter patients

Both non-intensive and intensive treatments involve taking a combination of anti-myeloma medicines.

But intensive treatment involves higher doses and is followed by a stem cell transplant.

The medicines usually include a chemotherapy medicine, a steroid medicine, and one or more of thalidomide, bortezomib and daratumumab.

Chemotherapy

Chemotherapy medicines kill the myeloma cells. A number of treatments are often combined to treat multiple myeloma.

These treatments are often taken in tablet form.

Side effects are usually mild, but may include:

• increased risk of infections
• feeling sick
• getting sick
• hair loss
• damage to nerves (neuropathy)

Your clinician will give you advice and information about your risk of developing potentially serious infections. They'll also tell you what you can do to reduce your risk.

Steroids

Corticosteroids help destroy myeloma cells and make chemotherapy more effective.

The most common types used to treat myeloma are dexamethasone and prednisolone.

Steroids are taken by mouth after eating.

Possible side effects include:

• heartburn
• indigestion
• increased appetite
• mood changes
• problems sleeping (insomnia)

Thalidomide

Thalidomide can help kill myeloma cells. You take it as a tablet every day – usually in the evening, as it can make you feel sleepy.

Other common side effects include:

• constipation
• dizziness
• rashes
• numbness or tingling in the hands and feet (peripheral neuropathy)

Thalidomide can cause birth defects, so should not be taken by pregnant women, and a reliable form of contraception such as a condom must be used during treatment.

There is also a risk you may develop a blood clot when taking thalidomide, so you may be given medicine to help prevent this.

Contact your care team immediately if you develop symptoms of a blood clot, such as pain or swelling in one of your legs, or chest pain and breathlessness.

Myeloma UK: thalidomide treatment guide

Bortezomib

Bortezomib (Velcade) can help kill myeloma cells by causing protein to build up inside them.

There are some limitations as to who can have bortezomib, but a member of your care team will discuss this with you.

The medicine is given by injection, usually under the skin.

Possible side effects include:

• tiredness
• diarrhoea
• numbness or tingling in your hands and feet (peripheral neuropathy)

Myeloma UK: bortezomib treatment guide

Daratumumab

Daratumumab helps kill the cancerous myeloma cells.

It can be used to treat myeloma in people who are suitable for a stem cell transplant. It is also used to treat relapses of myeloma.

Daratumumab is given as an injection or directly into a vein (a drip).

Your haematologist will discuss possible side effects with you.

The first dose can cause a reaction called an infusion reaction. If this happens you'll be given medicine to stop the reaction.

Myeloma UK: daratumumab treatment guide

Stem cell transplant

People receiving intensive treatment are given a much higher dose of chemotherapy medicine as an inpatient to help destroy a larger number of myeloma cells.

This aims to achieve a longer period of remission (where there is no sign of active disease in your body) but does not result in a cure.

However, these high doses also affect healthy bone marrow, so a stem cell transplant will be needed to allow your bone marrow to recover.

In most cases, the stem cells for the transplant will be collected from you before you are admitted for the high-dose treatment. This is called an autologous transplant.

In very rare cases, they are collected from a sibling or unrelated donor.

If you have an autologous transplant soon after being diagnosed, you may also need to take a medicine called lenalidomide. Lenalidomide helps prevent your symptoms from getting worse or returning.

Treating relapses

Further treatment is needed if myeloma returns. Treatment for relapses is similar to initial treatment, although non-intensive treatment is often preferred.

A small group of people may benefit from a second course of high-dose treatment, which your haematologist would discuss with you.

Additional medicines – such as lenalidomide, pomalidomide and carfilzomib – and other chemotherapy medicines may also be given.

You will also have a stem cell transplant if the first transplant worked well.

You may also be asked if you want to participate in clinical trial research into new treatments for multiple myeloma.

Lenalidomide and pomalidomide

Lenalidomide and pomalidomide are similar to thalidomide.

They're both taken by mouth and can affect the cells produced by your bone marrow, which can cause:

• increased risk of infection – as a result of a low number of white blood cells
• anaemia – caused by a low number of red blood cells
• bruising and bleeding – because of a low platelet count

They may also increase your risk of developing a blood clot and have other side effects similar to thalidomide.

Let your care team know if you experience any problems or unusual symptoms while taking lenalidomide or pomalidomide.

Myeloma UK: lenalidomide treatment guide

Myeloma UK: pomalidomide treatment guide

Carfilzomib

Carfilzomib is a medicine similar to bortezomib.

However, unlike bortezomib, it's given on a regular basis as a long-term treatment.

It's also given as an injection into the veins (intravenous) rather than under the skin (subcutaneous).

Carfilzomib is a more intensive treatment than bortezomib.

Possible side effects include kidney damage and, less commonly, nerve damage.

Carfilzomib can be taken with dexamethasone and lenalidomide. But only if you’ve had 1 previous treatment that included bortezomib.

Your haematologist will give you advice about which treatment is best for you.

Myeloma UK: carfilzomib treatment guide

Ixazomib

Ixazomib citrate (Ninlaro, Takeda) is used to treat multiple myeloma in adults who have had 2 or 3 other therapies.

Ixazomib is given as a tablet once a week on days 1, 8, and 15 of a 28-day treatment cycle, and is taken alongside lenalidomide and dexamethasone.

Myeloma UK: treatment for relapsed myeloma

Isatuximab

Isatuximab is a new antibody treatment that is used to treat multiple myeloma in adults where 3 other treatments have not worked.

It's taken with pomalidomide and dexamethasone, and is in the same group of medicines as daratumumab.

Isatuximab is given as an intravenous drip on a long-term, regular basis.

It has many possible side effects, including infections, a high temperature, diarrhoea and feeling sick, but each person is different.

Myeloma UK: isatuximab treatment guide

Panobinostat

Panobinostat is a treatment for multiple myeloma. It's given as a tablet over a few months, alongside bortezomib and a steroid tablet.

Its main side effects include diarrhoea, fatigue and low blood counts.

It can occasionally cause heart problems, but your haematologist will discuss the possible side effects with you.

Myeloma UK: panobinostat treatment guide

Treating symptoms and complications of myeloma

As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

• painkillers – to reduce pain
• radiotherapy – to relieve bone pain or help healing after a bone is surgically repaired
• bisphosphonate medicine given as tablets or by injection – to help prevent bone damage and reduce the levels of calcium in your blood
• blood transfusions or erythropoietin medicine – to increase your red blood cell count and treat anaemia
• surgery – to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back)
• dialysis – may be required if you develop kidney failure
• plasma exchange – treatment to remove and replace the liquid that makes up blood (plasma) if you have unusually thick blood

These treatments can each cause side effects and complications. Make sure you discuss the potential risks and benefits with your treatment team.

Clinical trials and research

Research is ongoing to find new treatments for multiple myeloma and work out ways to improve the use of existing ones.

To help with this, you may be asked to take part in a clinical trial during your treatment.

Clinical trials usually involve comparing a new treatment with an existing one to see whether the new treatment is more or less effective.

It's important to remember that if you are given a new treatment, there's no guarantee it will be more effective than an existing treatment.

There will never be any pressure for you to take part in a trial if you don't want to.

Myeloma UK: clinical trials