Managing Bone Disease With Multiple Myeloma
Bone disease is a common but challenging complication of multiple myeloma. More than 80% of myeloma patients suffer from bone lesions leading to pain, fractures, spinal cord compression and mobility issues. In normal bone developments, osteoclasts are cells that breaks down bone so it can be re-absorbed by the body. Osteoblasts generate new bone. These two processes usually work in harmony to constantly regenerate new bone while eliminating old bone.
In myeloma, this harmony is disrupted. The osteoclast process is increased while the osteoblast process is decreased, causing bone destruction in two ways.
Myeloma bone disease can impact overall survival. Myeloma patients who develop pathologic fractures have a 20% increased risk of death. As many patients know, managing bone pain or other bone issues also increases treatment costs.Myeloma patients with bone disease need not only anti-myeloma treatment, but treatment to strengthen bone, provide pain control and some patients may need radiotherapy or surgical interventions.
The majority of myeloma patients (70–80%) suffer from pain, and this could be the major complaint at the time of diagnosis. Experts recommend using a pain assessment scale from 0-10. A score of 5 or above would be moderate to severe pain and patients should be referred to a pain management team. For mild pain, Tylenol or similar paracetamol can be used. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) like aspirin, Motrin, Advil or Aleve should be avoided because they could affect the kidneys. Patients with moderate to severe pain may need opioids like tramadol, oxycodone, fentanyl patches, and morphine. However, side effects from these opioids (like sedation, neurological effects and constipation) should be watched in all patients, especially the elderly.
Historically, radiotherapy has been an important part of myeloma treatment. Radiotherapy can be used if a patient has a single bone plasmacytoma and could be curative in some cases. It can also be used as a pain control measure, reduce spinal cord compression, pathological fractures, soft tissue plasmacytomas, and control local neurological symptoms. The major risk of radiotherapy is permanent bone marrow damage, which can affect the ability to harvest stem cells for future transplants. The most common use of radiotherapy is for pain control, which historically has provided a 90% success rate.
This is a minimal invasive procedure, carried out under local or general anesthesia. Vertebroplasty includes the injection of bone cement into a vertebrae to stabilize the bone or to provide pain relief. Kyphoplasty is the same type of procedure where inflatable balloon is placed into the vertebral body to expand it and then followed by injection of bone cement. Potential complication of this procedure is cement leakage which could cause nerve irritation or cord compression and embolization of cement.