NURSING GUIDELINES FOR ENHANCED PATIENT CARE
Bertolotti, P. (1), Bilotti, E. (2), Colson, K. (3), Curran, K. (4), Doss, D. (3), Faiman, B. (5), Gavino, M. (6),
Jenkins, B. (7), Lilleby, K. (8), Love, G. (9), Mangan, P.A. (10), McCullagh, E. (11), Miceli, T. (12), Miller, K. (13),
Rogers, K. (14), Rome, S. (15), Sandifer, S. (16), Smith, L. (16), Tariman, J. (17), Westphal, J. (18), Durie, B.G.M. (15)
Abstract
Steroids
Thromboembolic Events (TE)
Introduction. Patients with multiple myeloma require
Issue Statement
Issue Statement
education and support to receive and adhere to optimal
Certain populations are at increased risk for TE, including
therapy. The International Myeloma Foundation (IMF)
Steroids are the basis of therapy in patients with multiple
deep vein thrombosis (DVT), pulmonary embolism (PE),
recognizes that nurses play an essential role in managing
myeloma, as their use leads to apoptosis of myeloma cells due
transient ischemic attacks (TIA), and stroke. Patients with
patient care, and that there is a need for specific nursing
to inhibition of IL-6, a major growth factor.2 Steroids can affect
cancer are among those with an increased risk for TE, and
guidelines, particularly for the use of novel anti-myeloma
multiple systems in ways that may significantly impact the
patients with multiple myeloma may incur an even higher
agents, such as proteasome inhibitors and immunomodulatory
physical, social, and psychological function of patients, with the
incidence of TE.
drugs.
potential to ultimately lead to decreased quality of life and
TE can produce life-altering complications affecting
Methods. A permanent Nursing Leadership Board (NLB) was
compliance with treatment.
breathing, cognition, and overall function, and should be
created in partnership between the IMF and 20 U.S. oncology
Adverse effects of medications often decrease patient
considered a medical emergency. TE can forever affect the lives
nurses from leading cancer centers caring for patients with
compliance and lead to less than effective dosing, impacting
of both patients and their families. Impairment resulting from TE
multiple myeloma. A pre-meeting needs assessment survey
treatment and survival outcomes. These management guidelines
can interfere with continuing therapy, treatment options, and
identified key NLB needs. A two day, on-site brainstorming
include 1) strategies that may increase patient compliance,
patient compliance.
meeting followed that included presentations, group
which in turn may lead to optimal responses to therapy, and
Recommendations for the prevention of TE in patients with
discussions, feedback surveys, break-out groups, and
increase quality of life; 2) IMF consensus recommendations for
multiple myeloma are dependent upon institutional practice,
consensus-building exercises. Post-meeting exchanges of
dealing with the potential adverse effects of steroid treatment on
drug therapies and combinations, as well as factors specific to
information were conducted to create issue and position
multiple systems in patients with multiple myeloma.
individual patients, i.e., concomitant illnesses, medical history,
statements and establish consensus guidelines and
cost, insurance, patient's abilities, compliance, and allergies or
recommendations that could be used by nurses in any type of
Peripheral Neuropathy (PN)
sensitivities.
medical facility.
Patient education, focused nursing assessment and
Results. The survey and meeting highlighted the need for
Issue Statement
proactive prophylaxis for TE may increase positive patient
specific nursing guidelines, strategies, and programs to
PN has significant impact on patient's quality of life (QOL)
outcomes. These nursing opportunities include identifying and
educate and assist patients in managing key side effects of
including the physical, social, and psychological effects of
recommending TE prophylaxis in conjunction with the health
novel agents used to treat myeloma. Steroid toxicities,
unrelieved neuropathic pain.
care team, and implementation of a prophylaxis algorithm such
peripheral neuropathy, gastrointestinal side effects (nausea,
PN associated with novel therapies should be addressed in a
as NCCN guidelines3, IMF Working group consensus4, MMNLB
vomiting, diarrhea, and constipation), thromboembolic events
timely manner.
DVT prophylaxis guidelines, and other nursing practices that
(deep vein thrombosis and pulmonary embolism), and
Neuro-assessments should take place at first encounter
have been identified as reducing the risk of TE.
myelosuppression (including thrombocytopenia, neutropenia,
(baseline), at the onset of worsening neuropathy, and at each
Global Statement
anemia, infection, and fever) were selected for the first
consecutive encounter when clinically indicated, particularly
TE prophylaxis recommendations depend on institutional
consensus issue statements and recommendations. Guidelines
while on novel therapy.
practices as well as factors specific to individual patients, i.e.,
were developed within breakout groups, followed by review by
Patient education about early reporting of PN may help avoid
concomitant illnesses, medical history, cost, insurance, patient's
the whole NLB with IMF input. Guidelines include identification
irreversible peripheral nerve damage.
abilities, adherence, and an individual's sensitivities.
of toxicity by grade, patient education opportunities and
Nurses should evaluate patient's ability to perform activities of
information, and both pharmacologic and non-pharmacologic
daily living (ADLs) and instrumental ADL (IADL) secondary
management strategies. Strategies include recommendations
activities related to independent living and safety issues at
Myelosuppression
for managing the side effects in general, along with specific
home, and employ interventions such as home health care
recommendations pertaining to the novel agents.
services in patients with PN interfering with ADL or IADL.
The side effects in the myelosuppression category include:
Interdisciplinary management of PN based on available
Thrombocytopenia
resources (i.e., pain service, neuro-service, psychosocial
Neutropenia
Specific Nursing Guideline Needs
service, physical therapy) is highly encouraged.
Anemia
Cancer treatment facilities must adopt policies that facilitate
Infection
Fever
Novel therapies for myeloma include proteasome
interdisciplinary trials addressing the management of
neuropathic pain.
Issue Statement
inhibitors and immunomodulatory drugs (IMiDS). The
Nurses should use adult verbal or non-verbal pain scales for
Nursing Leadership Board (NLB) selected the following
Myelosuppression is a common and expected side effect
assessing neuropathic pain, and be guided by the world health
side effects associated with the use of novel therapies
associated with novel therapies for treatment of multiple
organization (WHO) ladder of pain management.
for myeloma for their first Management Guidelines for

myeloma. As a result of myelosuppression, patients may
Adequate management of PN will increase mobility and
experience anemia, neutropenia, and thrombocytopenia.
Nurses Treating Patients with Multiple Myeloma:
promote patient safety, increase therapy adherence, increase
Depending on their severity, these adverse effects can impact
self-esteem, prevent unnecessary pain and discomfort, prevent
Steroid toxicities
patients' medical treatment and quality of life. Physiologically
muscle wasting, and improve QOL.
they can lead to life threatening complications and therapy
Peripheral neuropathy
interruption. Psychologically patients can experience a limited
Gastrointestinal (GI) Side Effects
ability to interact or work outside the home, resulting in
Gastrointestinal side effects
depression, anger, financial burden, and a sense of social
Issue Statement
Thromboembolic events
isolation.
GI toxicity is a common problem in cancer patients that is
Future Directions
Myelosuppression
frequently due to chemotherapeutic agents, and while often
addressed, may not be adequately managed. Inadequate
The next steps that will be taken include:
management of nausea, vomiting, constipation, and/or diarrhea
Management Guideline Contents
can affect the patient in multiple ways. Psychologically, patients
Publication of the first five Management Guidelines for
may experience more anxiety and depression. The physical
Nurses Treating Patients with Multiple Myeloma
Each Management Guideline followed an overall
effects are obvious and can lead to decreased adherence to the
structure, modified as appropriate for the specific side
treatment regimen. Socially patients may become isolated and
·Peer-reviewed nursing literature
effect and therapies, and included some or all of the
certainly have decreased work abilities. GI toxicities are
common sequelae of treatment with novel therapies.
·Monograph with internet-based distribution
following:
Dissemination of the Management Guidelines to
Side effect-specific issue statement
Adequate management of GI toxicities will:
Increase patient adherence to treatment regimen.
nurses via:
Position statement
Decrease physiological impairment.
·CME, symposia, and regional meetings

Improve quality of life for patients and their caregivers.
Background pathophysiology
Prevent serious adverse events that lead to prolonged
Educational materials, IMF hotline
Patient and caregiver educational recommendations
hospitalization, and increased morbidity and mortality.
Dissemination of Management Guideline information
Strategic recommendations statement
to patients via:
Toxicity and risk assessment tools for grading1 and
·Educational materials
management
References
·Presentations to patient support groups
Recommendations for prophylaxis
1.
National Cancer Institute (NCI) Common Terminology Criteria for Adverse
Identification of additional side effects and patient
Events (CTCAE) v3.0
Pharmacologic intervention recommendations
2.
Alexanian et al, Blood 1992;80:887
concerns for which management guidelines are needed,
3.
National Comprehensive Cancer Network (NCCN) Practice Guidelines in
e.g., osteonecrosis of the jaw, falls
Non-pharmacologic management approaches
Oncology
4.
Durie at al., Blood 2006;108 (Abstract 3571)
Modification of current and future Management
References
Guidelines for international use
(1) Samuel Oschin Comprehensive Cancer Center, (2) St. Vincent's Comprehensive Cancer Center, (3) Dana Farber Cancer Institute, (4) University of Pittsburgh Medical Center, (5) Cleveland Clinic, (6) MD Anderson Cancer
Center, (7) Myeloma Institute/University of Arkansas Medical Center, (8) Fred Hutchinson Cancer Research Center, (9) H. Lee Moffitt Cancer Center and Research Institute, (10) Hospital of the University of Pennsylvania, (11) Memorial Sloan
Kettering Cancer Center, (12) Mayo Clinic, (13) Roswell Park Cancer Institute, (14) Sidney Kimmel Comprehensive Cancer Center, (15) Cedars-Sinai Medical Center, (16) Cancer Center of the Carolinas, (17) University of Washington School of
Nursing, (18) Meeker County Memorial Hospital
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