Getting a diagnosis of cancer can be a terrifying and life-changing event for individuals and their families. The stress and fear of the unknown can get even sharper when the diagnosis is for a particularly rare cancer with no known cause or cure like multiple myeloma. Fortunately for oncological pharmacists with multiple myeloma patients, research has found several effective treatment compounds and combinations. In particular, the corticosteroid compound dexamethasone has proven effective as a treatment method and a compound to combine with other therapies.
Preferred Treatment Regimens with Compound Dexamethasone Only
Like many cancers, treatments for multiple myeloma depend on the level of severity, the cancer’s presence in other systems and the patient’s overall health. Dexamethasone is one of several compounds that a pharmacist can use for MM treatment, including lenalidomide, thalidomide, and bortezomib in various compounded formulas and doses. It’s crucial for the pharmacist to think of MM treatment as a sequence of therapies, with constant assessment and adjustments if necessary.
There are two primary instances in which compound dexamethasone would be used on its own: for high-dose treatment for patients whose patient profile does not allow use of bortezomib, lenalidomide, thalidomide, or any combination therein (for instance some kind of renal failure might preclude use of lenalidomide); and for newly diagnosed patients who are transplant-eligible and can be treated with low-dose dexamethasone (VTd).1
When used in high doses as a direct treatment, dexamethasone can actually kill myeloma cells. The International Myeloma Foundation found that dexamethasone is the best agent for treating multiple myeloma in large doses without combination therapy, though side effects in those cases can include weakening of the immune system and bone integrity.
In studies of high-dose dexamethasone against a combination treatment with lower or intermittent doses, it was found that high-dose treatment lowers the risk for serious complications when compared with the intermittent doses. Patients taking high doses of dexamethasone exhibited serious complications four percent of the time, compared with 27 percent for patients on lower or intermittent doses.2
Using Compound Dexamethasone in Combination Myeloma Treatments
While high-dose dexamethasone has proven effective, it’s when compound dexamethasone is used in combination treatments that its value becomes clear. Its flexibility allows it to become a crucial part in making risk-adapted myeloma treatments more effective and less systemic for patients. Particularly in front-line therapy, where the aim is to reduce the tumor as much as possible either for long-term disease control or as preparation for stem-cell transplants, dexamethasone is one of the key compounds in the most effective compound treatments.
For instance, a preferred induction treatment for a newly diagnosed MM patient with standard risk could be the compound drug “RVd,” made up of Revlimid, Velcade, and dexamethasone. Depending on patient assessments, the compound medication “CyBorD” has also proven effective, made up of cyclophosphamide, bortezomib, and dexamethasone, and also typically seen in induction therapy for newly diagnosed MM.3
Immunomodulatory compounds lenalidomide and thalidomide, as well as the relatively new compound bortezomib, have been shown in studies to improve the efficacy of dexamethasone. Lenalidomide plus dexamethasone has also proven effective for patients who have gone through at least one cycle of prior therapy, which gives providers increased flexibility for patients who have a relapsing condition.4
Also important for supply chain concerns, compound dexamethasone remains relatively stable in various delivery systems, including oral and intravenous syringes, and plastic and glass bottles. When a compounding pharmacist follows the guidelines for preparing the dexamethasone suspensions, they were found to stay stable throughout the 91-day test period. The suspensions maintained 96 percent of the original dexamethasone concentration during that time, and the study considered the compounds to be stable at 90 percent.5
Additional Considerations for Pharmacists Treating Multiple Myeloma
Although they are crucial for MM treatment on their own or with other drugs, corticosteroids like dexamethasone play a much bigger role in treatment for MM if the patient presents existing peripheral neuropathy. Like peripheral neuropathy that might present itself during other chronic conditions, the neuropathy related to multiple myeloma treatments can be painful and detrimental to patient health if not managed properly.6
Dexamethasone dosing can help slow further drug-induced peripheral neuropathy in patients with existing symptoms. Oncologists have found that RVD, Revlimid (lenalidomide) plus Velcade (bortezomib) and dexamethasone, showed much lower-than-expected rates of neuropathy, in the two to three percent range. This may be due to lenalidomide’s anti-inflammatory qualities or that dexamethasone combined with bortezomib reduces its usual neuropathy-inducing effects. The pain itself can also be treated with gabapentin, pregabalin, or tricyclic antidepressants.7
Pharmacists should also consider all supportive care and toxicity considerations. Therapies involving compound dexamethasone are arguably among the safest treatments, but patients should still be reminded to take corticosteroids in the mornings and watch for an increase in hunger and glucose levels. The latter should be monitored for clinical significance and to monitor for hyperglycemia.
As with any illness where there is no known cure and many factors affecting survival rates, pharmacists also need to work with their patients’ needs and their own clinical assessments to determine where on the “cure v. care” spectrum that particular patient’s situation falls. Many pharmacists choose to treat MM like a chronic condition where therapies are aimed at promoting remission and managing quality of life.
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“Pharmacy Perspectives in Multiple Myeloma: Sequencing Therapy,” Dec. 23, 2014, http://www.medscape.org/viewarticle/834031_3 ↩
“Primary Dexamethasone Treatment of Multiple Myeloma,” Aug. 15, 1992, http://www.bloodjournal.org/content/bloodjournal/80/4/887.full.pdf?sso-checked=true ↩
“Cyclophosphamide, bortezomib and dexamethasone (CyBorD) induction for newly diagnosed multiple myeloma: High response rates in a phase II clinical trial,” July 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711213/ ↩
“Lenalidomide, bortezomib and dexamethasone combination therapy in patients with newly diagnosed multiple myeloma,” Aug. 5, 2010, http://www.bloodjournal.org/content/bloodjournal/116/5/679.full.pdf ↩
“Stability of extemporaneously compounded dexamethasone in glass and plastic bottles and plastic syringes,” July 2014, http://www.ncbi.nlm.nih.gov/pubmed/25214658 ↩
“Chemotherapy and other drugs for multiple myeloma,” March 9, 2015, http://www.cancer.org/cancer/multiplemyeloma/detailedguide/multiple-myeloma-treating-chemotherapy ↩
“Drug-Induced Peripheral Neuropathy In Multiple Myeloma Patients–Part 1: What Is It And Who Is At Risk?” Mar. 26, 2012, http://www.myelomabeacon.com/news/2012/03/26/drug-induced-peripheral-neuropathy-in-multiple-myeloma-patients-part-1-what-is-it-and-who-is-at-risk/ ↩
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