How to Manage Neutropenia in Multiple Myeloma
ABSTRACT Neutropenia is a hematologic adverse event characterized by an absolute neutrophil count (ANC) lower than 1500 cells/mL. This reduction may be due to decreased neutrophil production, accelerated use, a shift in compartments of neutrophils, or a combination of these factors. Neutropenia is often associated with infections, which are major causes of morbidity and mortality in patients with cancer. In patients with multiple myeloma, the novel agents thalidomide, lenalidomide, and bortezomib have improved outcome, but chemotherapy-related neutropenia should be carefully considered. Chemotherapy-related high-risk factors for severe neutropenia include regimens with an expected neutropenia rate of > 50%, such as the 3-drug combinations including lenalidomide plus alkylating agents or doxorubicin, whereas low-risk regimens include combinations of the novel agents with dexamethasone alone. Patient characteristics, disease stage, type of current and previous treatment, and ANC < 1000 cells/mL at baseline are additional factors that define the risk of severe neutropenia. Granulocyte-colony stimulating factor (G-CSF) should be used to manage chemotherapy-related neutropenia so that patients may stay on treatment for a longer time and benefit from it. Primary G-CSF prophylaxis should be used when high-risk regimens are administered or when low/intermediate-risk regimens are used and additional risk factors are present. Reactive G-CSF treatment is indicated when patients undergoing low-risk chemotherapy experience grade 3/4 neutropenia. If ANC restores to > 1000 cells/mL, therapy can be resumed with no dose modifications. In case of persistence of severe neutropenia, treatment should be delayed until ANC reaches > 1000 cells/mL, and dose reductions are necessary.
Clinical Lymphoma, Myeloma and Leukemia 06/2014; DOI:10.1016/j.clml.2014.06.001 · 1.93 Impact Factor
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ABSTRACT: To provide an update on recent advances in the management of patients with multiple myeloma who are not eligible for autologous stem-cell transplantation. A comprehensive review of the literature on diagnostic criteria is provided, and treatment options and management of adverse events are summarized. Patients with symptomatic disease and organ damage (ie, hypercalcemia, renal failure, anemia, or bone lesions) require immediate treatment. The International Staging System and chromosomal abnormalities identify high- and standard-risk patients. Proteasome inhibitors, immunomodulatory drugs, corticosteroids, and alkylating agents are the most active agents. The presence of concomitant diseases, frailty, or disability should be assessed and, if present, treated with reduced-dose approaches. Bone disease, renal damage, hematologic toxicities, infections, thromboembolism, and peripheral neuropathy are the most frequent disabling events requiring prompt and active supportive care. These recommendations will help clinicians ensure the most appropriate care for patients with myeloma in everyday clinical practice.Journal of Clinical Oncology 01/2014; 32(6). DOI:10.1200/JCO.2013.48.7934 · 17.88 Impact Factor
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ABSTRACT: Escherichia coli (E. coli) is a pathogen of great concern in immunosuppressed patients. While antimicrobial prophylactic therapy has become the standard, the emergence of resistant pathogens has some questioning its use. This study describes our experience with E.coli as a pathogen in neutropenic patients with a hematologic malignancy, and addresses future directions of treatment for this patient population. A retrospective chart review of 245 E.coli bacteremia patients at Moffitt Cancer Center from 05/18/02 - 05/15/12 was conducted. Out of 245 patients, 169 did not meet the criteria due to non-neutropenic status, or not diagnosed with a hematologic malignancy, or due to having insufficient medical records. Thus, they were excluded from the study. As a result, 76 patients were involved in this study. Patients were identified via microbiology laboratory computerized records. The included patients experienced clinically significant E.coli bacteremia resulting in a median hospital stay of 14.7 days. Several patients developed severe sepsis requiring the use of pressor and ventilator therapy. E.coli is a major pathogen in these patient populations resulting in extended hospital stays and specialized treatment to overcome their E.coli bacteremia. The data supports the use of fluoroquinolone prophylactic therapy, however, earlier detection and treatment of neutropenic infection is needed.Mediterranean Journal of Hematology and Infectious Diseases 01/2014; 6(1):e2014068. DOI:10.4084/MJHID.2014.068