People with multiple myeloma may experience symptoms related to their disease or their chemotherapy regimen. Hypertension, fluid retention, or diabetes mellitus may be affected by dexamethasone. Depression or fatigue might lead to loss of appetite and weight loss. Iron deficiency could be due to blood loss or malabsorption from proton pump inhibitors which could lead to anemia, fatigue, decreased level of activity and weakness.
Some helpful tips for a healthy diet while dealing with all aspects of multiple myeloma are: Low salt, low fat, high potassium, high fiber (30 grams per day- found in beans, whole grains, brown rice), 8-10 servings of fruits and vegetables daily, small amounts of lean red meat, fish or poultry, vitamin D (800-1000 IU) and calcium (1000-1200 mg daily), iron 8 mg per day, avoid high fat red meat or processed meat (for colon health).
at frequent small meals, avoid large meals close to bedtime, keep hydrated (2-3 liters of fluids per day taken early in day and avoid drinking fluids within 2 hours of bedtime), moderate alcohol intake if desired (1-2 glasses wine or 1 beer or 1 cocktail). Oral hygiene (brush and floss) after meals and at bedtime is important to reduce risk of infections and oral cancer.
Always check with your doctor, nurse practitioner or nutritionist for recommendations specific to your condition.
The term cancer
survivor applies to any person diagnosed with cancer. There are currently 12 million cancer
survivors in the United States with 68 % of those expected to live at least
five years. Survival rates for patients
diagnosed with Myeloma have improved significantly in the last decade due to improved
diagnostics, treatment options and supportive care. Living
and feeling well while surviving cancer is a universal goal for cancer
survivors. Wellness requires an
individualized approach with a focus beyond the just the cancer diagnosis
including tailored screening, health promotion and management of other
illnesses. A number of health care
providers from many disciplines may be involved in the continued care of
patients living with Myeloma. Patients
and caregivers play a critical role in planning, monitoring and modifying their
There are several
recommendations for taking an active part in living well after the diagnosis of
Myeloma - a survivorship plan.
Understanding the diagnosis of Myeloma, tracking treatment plans and
outcomes including laboratory results, results of radiology testing, and any
side effects of treatment will provide a quick summary of the treatment history
which can be shared with all members of the health care team. Maintaining a current medication list,
contact information for all health care providers and copies of any reports or
recommendations will help to integrate these recommendations into a healthy
lifestyle. Seeking additional
recommendation for a healthy diet, exercise guidelines specific to the Myeloma
patient, recommendation for health care screening for other types of cancer,
heart disease, diabetes, and osteoporosis is encouraged. Organizing this information, assembling a
health care team that includes physicians, nurses, dieticians, social workers,
financial counselors, and other Myeloma survivors will provide the best
opportunity to live and feel well. Many
resources for understanding the diagnosis and treatment of Myeloma and
suggestions for staying well can be found on the International Myeloma
Foundation website: www.myeloma.org
YES! The kidneys play
an important role in the health of each individual. Their main function is to clear toxins and
waste from our bodies. Approximately 25% of individuals with multiple myeloma
(MM) will have temporary or permanent damage at some point during their
What health conditions
or medications can affect the kidneys?
Many health conditions
(aside from MM) can cause the kidneys to work less efficiently. These are too
numerous to list. However, more common conditions include: longstanding
diabetes, high blood pressure, other plasma cell disorders such as amyloidosis,
and dehydration. Enlarged prostate glands or kidney stones can also cause
kidney damage. Some medications can harm
the kidneys. These include non-steroidal
anti-inflammatory agents (such as Motrin and ibuprofen), certain intravenous
antibiotics (gentamycin, vancomycin), and water pills (called diuretics).
Bone-building drugs called "bisphosphonates" can also damage the kidneys, so
your healthcare provider will monitor your kidneys with each dose. Intravenous contrast dye when given before a
CT scan procedure can also harm the kidneys of MM patients. Therefore, this
must be given in special situations, and the MM patient must drink lots of
How does the MM affect
Basically, there is a network
of cells in the kidney called the glomerulus. This is responsible for filtering "light
chain" proteins before these are excreted in the urine. Too many
immunoglobulins or urinary light chains can easily overwhelm the kidneys until
they are unable to do their job. The
increased proteins in the urine can "clog" the kidneys and lead impaired kidney
Does my healthcare
provider monitor my kidneys, and what should I look for?
Your healthcare provider
should be checking your serum creatinine levels each month. The normal range
varies, but is generally between 0.5-1.4mg/dL of blood. If the creatinine
begins to increase, your healthcare provider will review your medication list
and see which medicines may have caused the rise in creatinine. Then, he or she will determine if you have
become dehydrated by not drinking adequate amounts of fluid (usually one needs
about 64 ounces of fluid per day), or as a result of using water pills
(diuretics) to manage your blood pressure or swelling. An elevated creatinine
may be a sign that the MM is becoming active, but it may also be a result of a
separate health condition.
Notify your healthcare provider
if you have any pain during urination, or change in your urinary habits. Let he
or she know if you have developed any pain or blood in the urine. Drink lots of
fluids to stay well hydrated. Eat a well-rounded diet with fruits, vegetables
and proteins unless you have been placed on dietary restrictions. And, as
always, discuss any medications and supplements with your healthcare provider
to make sure these do not interact with your cancer treatment.
Depression is a
major side effect that can affect you as a myeloma patient at some point in your
course of treatment. Depression in a myeloma patient undergoing treatment can
be challenging to diagnose as various side effects such as fatigue, pain, and
anemia may appear similar in both conditions. Your healthcare team will need to
distinguish the difference between the symptoms associated with your myeloma
treatment or clinical symptoms of depression. While feelings of sadness and
anxiety are typical with the diagnosis of cancer,
it is imperative to discuss
these symptoms with your healthcare team so they can help you appropriately.
Signs and symptoms of depression include persistent sadness, anxious mood, sleeping
too much, or too little, decreased appetite, weight loss or gain, restlessness,
and feelings of despair or denial. Chronic disease such as cancer, medication
side effects, gender, family history, situational events, biologic factors, and
cognitive changes, such as poor self-esteem and negative thinking patterns, are
all risk factors for depression.
Screening for Depression. There are
several questionnaires available that your provider may use to assist in
screening for depression. Once depression is correctly diagnosed, your
clinician may find it necessary to start an antidepressant, or may refer you to
a specialist such as a psychiatrist who specializes in oncology patients. It is
also important to differentiate between depression and anxiety. If you have an
oncology social worker available to you, they can be a valuable resource to
assist you with related challenges of financial difficulties, such as insurance
and housing issues, as well as social support. Many social workers are licensed
counselors and can provide their services for patients and family members
through counseling and group support sessions, usually without charge. Many
cities also have local chapters with disease specific support groups such as
monthly multiple myeloma support group meetings. To find a local support group (or to start one
in your area) please all the IMF Hotline at 1-800-452-CURE for assistance (818-487-7455 outside of the US and Canada.)These meetings can be beneficial for both
patients and caregivers. The NLB recommends asking the following questions during routine screening
at all provider encounters to detect depression or other cognitive changes:
Over the past two weeks have you felt down,
depressed or hopeless?
Over the past two weeks have you felt little
interest or pleasure in doing things?
Please be sure to
report any of these symptoms to your healthcare team.
Steroids have been in
integral part of myeloma therapy for many years and they continue to be used
today, often in combination with novel agents (thalidomide -Thalomid, lenalidomide
- Revlimid and bortezomib - Velcade).Steroids
can cause a wide variety of side effects affecting nearly every system of the
body.Education, early identification
and management of these side effects can contribute to the success of steroid-containing regimens for the treatment of myeloma and other associated disorders.
Possible Side Effects
One of the most common side
effects associated with steroid use is difficulty sleeping (insomnia).Steroids should be taken early in the morning
so that the medication will wear off by evening.It is possible some pharmacologic
intervention may be necessary, including taking a hypnotic or sedative.Other causes of insomnia need to be
considered as well, such as pain.You
should be aware of the signs and symptoms of infection, as steroids may mask
the signs of infection.our provider
should be notified if you are experiencing fevers (>100.5), shaking chills
with or without fever, dizziness, shortness of breath or low blood pressure.
Medications to prevent infection, such as
antibiotics or antiviral agents, may be prescribed.You should also be aware of possible fluid
retention (edema/swelling) in your legs or feet.If you experience edema, elevate the affected
limbs, use compression stockings, and increase activity.If necessary, pharmacologic intervention with
diuretics may be recommended.Another
side effect of steroid use is heartburn (dyspepsia).Steroids should be taken with food and
irritating or acidic food should be avoided.You may also benefit from over the counter or prescription medications,
These are just a few of the
potential side effects associated with steroid use.Contact your healthcare provider if any of
the side effects are not manageable.They
may prescribe additional medication or modify your treatment plan.You should never stop taking steroids without
notifying your provider.
disease is a condition caused by long term effects of multiple myeloma."Renal" refers to the kidneys, which is one
of the many body systems that can be harmed by multiple myeloma.The disease creates a great burden on the
kidneys in a variety of ways.You are
probably aware that the malignant plasma cells in the bone marrowproduce an antibody that is released into the
bloodstream.This antibody is a protein
and there can be very high levels of protein in the blood of myeloma
Additionally, multiple myeloma can cause the
breakdown of bone and the subsequent release of excess calcium into the
bloodstream.The kidneys work to filter
the body's blood supply and the excess protein and calcium that are present in
the blood can put a "strain" on the kidneys.They have to work exceptionally hard to filter the abnormally high
levels of protein and/or calcium in the blood.These conditions can cause "renal dysfunction" or "renal insufficiency,"
which means that the kidneys are no longer able to handle their jobs.In severe cases, this can lead to renal
failure, which means the kidneys are shutting down.Patients may have to undergo dialysis so
machines can perform the blood filtering function for the body.
How can you help
to protect your kidneys?An important
thing to remember is that you should not let yourself become dehydrated.It is
crucial that you stay well hydrated (e.g., making sure you drink enough plain water) as this will continuously flush your
kidneys which will help them function properly.You should avoid taking NSAIDs
(non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen and you
should avoid IV contrast dye (particularly the IV dye used with CT scans) as
these substances are taxing to the kidneys.You will want to seek advice from your oncologist before using these
If it is noted
that you are hypercalcemic (have a high level of calcium in your blood as
determined by a blood test), then your physician will want to treat you without
delay to lower your calcium level so that the kidneys are not damaged.We are also going to check your kidney
function before administering bisphosphonates, which are the bone-strengthening
agents used in multiple myeloma patients.These drugs are excreted by the kidneys so if your kidneys are not
functioning optimally, you may need dose adjustments of these drugs or your
physician may choose not to administer these agents.
important to note that those patients with myeloma renal disease can take
actions to relieve some of the burden on their kidneys.There are many treatment options available
for myeloma patients and many patients will also see an improvement in their
kidney function as the disease is controlled.
Have you found yourself not leaving the house or being too
far from a bathroom out of fear of having an "accident"? Diarrhea is defined as
an abnormal increase in the amount of fluid in stool. There are many causes for
diarrhea. Some people have baseline disorders like Crohn's Disease, Irritable
Bowel Syndrome (IBS) or allergies that result in diarrhea. For those receiving
treatment for MM, diarrhea can be the result of irritation to the bowel lining
from chemotherapy or infection. Bortezomib use is commonly associated with
diarrhea where thalidomide and lenalidomide are more commonly associated with
Severe or prolonged diarrhea can result in the loss of
important electrolytes like potassium. The increased loss of fluids can cause
dehydration and kidney problems. Bowel incontinence, or uncontrollable diarrhea,
can lead to emotional distress and limited freedom. It may also result in the
need for a change in treatment, dose, or schedule.
arrhea should always be reported to your health care
provider. Diarrhea with abdominal cramping may indicate an infection and the
need for additional treatment. Clostridium difficile (C. diff) is an infection
that can be associated with symptoms of diarrhea and abdominal cramping. People
who have been receiving antibiotics and/or chemotherapy are at greatest risk for
this infection. Ironically, the treatment for this antibiotic-related infection
is an antibiotic (i.e. metronidazole or vancomycin). Symptom management may
include hydration and electrolyte replacement. It is important to stay well
hydrated to replace the fluid that is lost. If stool sample is negative or there
is no concern for infection, over the counter medications to control diarrhea
may be started. Loperamide (Immodium) is used to slow down bowel motion to allow for more
fluid to be absorbed from the bowel, thereby reducing diarrhea. Fiber binding
agents (i. e. Metamucil or Citrucil) act like a sponge
to absorb extra fluid.
Diarrhea is not an easy topic to discuss and bowel
incontinence can be embarrassing. Despite this, diarrhea can result in
hospitalization, change in treatment, and reduced quality of life. Do not
hesitate to discuss with your health care provider even between scheduled
You have many items on the "To Do" list, but you just do not
have the energy to get them all done. Activities that normally take you no time
take all day to complete. You are experiencing fatigue. Fatigue is subjective
and very individual. In simplest terms, it is the feeling of being more tired
than the level of activity exerted. Fatigue often interferes with day to day
Fatigue may be related to medical conditions such as anemia
(low hemoglobin), low thyroid function or infection. It is one of the most
commonly reported symptoms at the time of diagnosis of multiple myeloma. Active
myeloma, treatment and side effects like dehydration or uncontrolled pain cause
fatigue. Steroids are often used in myeloma treatment. They initially can
cause insomnia and hyperactivity with a rebound effect of being fatigued.
Depression also contributes to fatigue.
Your health care provider may ask you to rate your level of
fatigue at baseline, or the start of treatment, and then throughout your
treatment. It is important to offer the information and discuss your level of
fatigue with your healthcare provider. If the level of fatigue is out of the
norm for your level of hemoglobin or cycle of treatment, this may lead to more
testing to find another cause.
Managing fatigue can be done by taking a proactive approach.
If fatigue is due to a medical condition like depression, anemia or infection,
treatment of the underlying condition will improve energy. Maintaining proper
nutrition, hydration and participating in a regular scheduled exercise program
have also been found to be beneficial to improve energy. Becoming aware of how
you react to medications will help in planning activities and adjusting your
schedule for times when you will have more/less energy. Fatigue may not be life
threatening, but it alters quality of life and should be discussed with your
health care provider.
Deep vein thrombosis (DVT and Pulmonary embolism (PE) are
the most common types of thromboembolism or thrombosis (blood clots).The risk of developing a blot
clot is increased in any patient with cancer for a number of reasons. Cancer
cells, including myeloma cells, release substances that may promote
thrombosis.MM patients may be less
active, may require hospitalization, often have other chronic illnesses such as
diabetes, coronary artery disease or high blood pressure hypertension), and commonly receive medications to
treat these chronic diseases which can increase the risk of developing a blood
clot.Surgical procedures such as
placement of a central venous catheter may also increase the risk. Some
patients may have a family history which puts them at increased risk of
thromboembolism.Smoking, obesity and a
sedentary lifestyle may also increase the risk of a blood clot.
Prevention of thromboembolism
The best strategy to reduce the risk of thromboembolism is to screen each patient carefully
for individual and disease related risk factors.Patients with any type of cancer, including
MM are considered to have one risk factor as a result of the diagnosis
itself.Treatment for MM with certain
drugs such as thalidomide, lenalidomide or doxorubicin may increase the risk of
thrombosis, particularly when combined with higher doses of dexamethasone (4
days in a row followed by 4 days off).Reducing the dexamethasone dose to once weekly has been shown to
decrease the risk of thrombosis while providing effective MM treatment.Effective treatment of the MM may reduce
the risk of thrombosis.
Notifying your health care provider for any symptoms that
may indicate thromboembolism such as painful swelling in an extremity (DVT) or
rapid onset of chest pain and shortness of breath (PE) will allow immediate
treatment and can reduce the risk of more serious complications.Daily physical activity, avoiding sitting for
long-periods of time, regular review of medications, weight loss and smoking
cessation can also reduce the risk of thrombosis.
Sandra E. Kurtin, RN, MS, AOCN, ANP-C
Hematology/Oncology Nurse Practitioner
Arizona Cancer Center
Clinical Assistant Professor of Nursing
Clinical Assistant Professor of Medicine University of Arizona Tucson, Arizona
Editor's Note: Use of any medications, even "over the counter" non-prescription medications and/or dietary supplements should always be discussed with your health care professional before taking any action.
Monitoring for infection is crucial for people with MM. For many people, their MM diagnosis came after experiencing pneumonia, shingles or some other infection. Myeloma compromises the immune function by disturbing the normal production of infection fighting antibodies. Therapies to treat myeloma also have the potential to compromise a person's ability to fight infection. As a result of compromised immune function, people are at risk of infection that could result in hospitalization or even death.
Awareness -Infections can occur from sources you already have in your body. For example, varicella zoster, or "shingles", is the reactivation of the herpes virus that causes Chicken Pox. Once exposed, the virus remains in our body for a lifetime. At times of immune compromise, it can become active. Infections can also be acquired from other people, food and water sources and environmental contaminants.
Prevention - There are ways to protect against infection. The simplest but most valuable is hand washing. It sounds too easy to be true, but hand washing with soap and water or liquid anti-septic solutions can reduce your exposure risk. At times when you know you are at greater risk due to treatment, avoid large crowds. When on treatment, your health care provider may prescribe preventative antibiotics. It is a common practice for patients receiving bortezomib (Velcade) to take an antiviral medication such as acyclovir to prevent "shingles".
Action - You are your own best advocate. If you develop any symptoms that indicate you have an infection, you should contact your health care provider. Symptoms may include fever, shaking chills, sore throat, diarrhea, sinus drainage or productive cough that is green in color, or shortness of breath. Skin wounds that are red, tender or have drainage may be infected. Shingles becomes active in a nerve track (dermatome) and tends to be a painful, red rash that has pimples, or fluid filled pustules. Often times the start of this rash is mistaken for a spider bite, but instead of getting better, it worsens. The earlier treatment is started, the better chance there is to reduce long term pain issues. Always contact your health care provider if you have any symptoms that may indicate an active infection.
Teresa Miceli, RN BSN OCN
BMT Nurse Coordinator
Mayo Clinic - Rochester