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January 2011 Archives : Nurse Leadership Board

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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

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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.

The International Myeloma Working Group (IMWG) suggests prevention strategies for patients with increased risk of thromboembolic events. For individuals with only one risk factor a daily dose of aspirin (81 or 325 mg) is recommended.  Use of prescribed anticoagulation medications such as low-molecular weight heparin  or warfarin (Coumadin) is recommended for patients with more than one risk factor.  These treatments do require close monitoring to be sure they are effective and no other side effects such as bleeding occur. 

What can you do to reduce your risk?

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.

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Miceli_Teresa_S Mayo 12.10.08.jpgMonitoring 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

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Beth Faiman, CNP

Peripheral neuropathy is a change in feeling in the hands, fingers, legs, toes, or other body parts.  It can be a symptom of myeloma or related to the use of medications used to treat myeloma, such as thalidomide (Thalomid) or bortezomib (Velcade).  Taking care of peripheral neuropathy is very important and requires that you pay careful attention to any symptoms and discuss them fully with your health care provider.  There are two types of peripheral neuropathy which most often affects myeloma patients  - sensory, motor.

Symptoms of sensory peripheral neuropathy include numbness, tingling, numbness or pain in the hands or feet, trouble hearing or ringing or buzzing in the ears, or weakness all over.  Symptoms of motor peripheral neuropathy include trouble fastening buttons, difficulty opening jars or trouble walking.  

You should always inform your healthcare provider if you experience any of these symptoms.  They may modify your treatment plan if these symptoms occur.  Your healthcare provider may also prescribe pain medications, physical therapy, or suggest other measures such as nutritional supplements such as folic acid, B-complex, or amino acid supplements.  You should always check with your healthcare provider before taking any new medications or supplements.

For more information about managing peripheral neuropathy, please see the IMF Patient Education Fact Sheet on Peripheral Neuropathy.

Beth Faiman, MSN, APRN-BC, AOCN
Cleveland Clinic Taussig Cancer Institute
Multiple Myeloma Program
Cleveland, OH

Editor's Note:  You can also view a video of Dr. Paul Richardson of the Dana Farber Cancer Institute speaking about peripheral neuropathy at the 2009 International Myeloma Workshop, held in Washington, DC.   This is a presentation to an audience of doctors and scientists, so it is a bit technical.
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