Key Points

Bortezomib is rapidly becoming the drug of choice internationally for myeloma. In New Zealand it is approved for use first line or second line in myeloma. Bortezomib has shown an overall survival advantage when used in first line therapy in the elderly in the VISTA trial (Dimopoulos et al, 2009) and gives rapid response rates when used as part of an induction combination for younger patients.

Thalidomide (when combined with melphalan and prednisone) has also shown a survival advantage when used first line for myeloma in those not eligible for auto SCT (Hulin et al , 2009). Thalidomide is also funded by PHARMAC for first line and all subsequent lines of therapy.

Lenalidomide is approved for use as second or third line therapy in myeloma and is now funded by PHARMAC. Special authority for subsidy can be obtained for treatment of relapsed / refractory myeloma with progressive disease, either as third line treatment or as second line in patients who have experienced severe (grade ≥3), dose-limiting, peripheral neuropathy with bortezomib / thalidomide that precludes further treatment with either of these agents.

Pamidronate 30 mg IV once per month for 2 years is the standard bisphosphonate for patients with myeloma who have documented bony disease or hypercalcaemia.

Clinical trials may allow access to newer agents and enrolment in available clinical trials is recommended

Urgent therapy could include intensive intravenous cyclophosphamide 1 g/m2 plus dexamethasone 40 mg daily for 4 days (or until improved) plus bortezomib 1.5 mg/m2 subcut day 1,4,8,11 for a first 3 week cycle.


About this Canterbury DHB document (7589):
Document Owner:	Amy Holmes (see Who's Who)
Last Reviewed:	September 2014
Next Review:	September 2016
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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