Wednesday, 4 December 2013

Multiple myeloma – Standard treatments In conventional medicine perspective

Multiple myeloma. also known as plasma cell myeloma or Kahler’s disease, is a types of abnormal growth of plasma cells collected in the none marrow where they grow and multiple to interfere with the production of normal blood cells. Paraprotein, an abnormal antibody produced by the plasma cell myeloma not only can cause kidney problem but also interference with the Roche automated total bilirubin assay caused by precipitate formation of that can cause clinical confusion, according to the study by the Harvard Medical School, Boston(1). Other study indicated that the production of paraproteins caused spurious results on individual analytes including total bilirubin (TBIL), direct bilirubin (DBIL), or HDL-cholesterol (HDL-C)(b). there is also a report of a 50 years old
chloride resistant metabolic alkalosis in a patient with hypercalcemia related to Multiple Myeloma (MM)(c).
VI. Treatments
A. In conventional medicine perspective
There is no cure for multiple myeloma. The aim of the treatment is to relieve the symptoms and bring back the normal quality of life in the patients.
A.1. Standard treatment
Thalidomide (T) and lenalidomide (R) had been used as first line therapy for previously untreated myeloma. In the study to to assess the treatment effects of lenalidomide-versus thalidomide-based regimen via common comparators, found that lenalidomide seemed to be a more potent and less toxic agent than thalidomide in the treatment of patients with multiple myeloma. Further the direct head-to-head trial comparing lenalidomide versus thalidomide is clearly warranted(51a). Other study indicated that LBCT is more efficient in the treatment of MM and has significant role in serum protein alterations especially in the reduction of M-protein in the MM patients(51b).
1. Immunomodulatory drugs (thalidomide, lenalidomide) and proteasome inhibitors (bortezomib, carfilzomib) and chemotherapy
Immunomodulatory drugs (thalidomide, lenalidomide) and proteasome inhibitors (bortezomib, carfilzomib) can induce apoptosis of myeloma plasma cells and suppress cytokine release and metabolic ways which sustain the disease. These novel agents demonstrate substantial activity either alone or as part of a range of combination regimens. MM therapy is now based on 1 or 2 new drugs plus standard chemotherapy, according to Azienda Ospedaliera Careggi(51). Other study indicated that although high-dose therapy with stem cell transplantation (SCT) and novel targeted therapies (thalidomide, its more potent analogues, and bortezomib) represent two approaches for overcoming resistance of multiple myeloma (MM) cells to conventional therapies, Gene expression profiling (GEP) will help to improve the management of MM not only by identifying prognostic subgroups but also by defining molecular pathways that are associated with these subgroups and that are possible targets for future therapies(52).
2. Corticosteroids
Corticosteroids may be used in patients of multiple myeloma with Disorder of glucose metabolism regulation. According to the study by Interní hematoonkologická klinika Lékarské fakulty MU a FN Brno, The deterioration of glucose tolerance leads to worsening of morbidity and mortality of seriously ill patients. In glucocorticoid-induced diabetes mellitus the highest levels of glucose are seen in the afternoon, in the evening and postprandially: Normal levels of glucose are seen in the morning. Excluding 11 patients with diabetes (16%), we idenfied 7 (10%) patients with normal glucose tolerance, 13 (19%) patients with impaired fasting glucose or/and impaired glucose tolerance and glucocorticoid-induced diabetes mellitus we found in 37 (55%) patients treated in our department with diagnosis of myeloma multiplex in the year 2004 intermitently with 40 mg dexamethason(53).
3. Radiation therapy for local symptoms
In the review of the experience at the University of Arizona in an effort to define the minimum effective radiation dose for durable pain relief in the majority of patients with symptomatic multiple myeloma of of 101 patients with multiple myeloma irradiated for palliation at the University of Arizona between 1975 and 1990, found that rtherapy is effective in palliating local symptoms in multiple myeloma. A total dose of 10 Gy should provide durable symptom relief in the majority of patients(54).
4. Stem cell transplantation
A high dose of melphalan followed by autologous stem cell transplantation (ASCT) is considered as the standard therapy for multiple myeloma(55).
5. Treatments and Supportive care
Treatment of younger fit patients with Multiple myeloma is with induction therapy consisting of steroids with one or more novel anti-myeloma agents followed by high dose melphalan and autologous stem cell transplantation, while older and less fit patients are treated with melphalan-based combination chemotherapy. Supportive care is of paramount importance and includes the use of bisphosphonates, prophylactic antibiotics, thrombosis prophylaxis and the use of hematopoietic growth factors along with the treatment of complications of disease and its therapy(56).
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