Myeloma Nurse Learning Programme Module 8 – Management of disease and treatment-related symptoms and complications in myeloma Treatment and management of myelosuppression

Treatment and management of myelosuppression

The treatment and management of myelosuppression depends on the underlying cause and severity of neutropenia, anaemia or thrombocytopenia as described below:

Treatment for neutropenia

Neutropenia caused by myeloma may improve with anti-myeloma treatments but treatment-related neutropenia may require dose reduction of the treatment concerned. Each situation should be treated on an individual basis.

If neutropenia continues and infections become recurrent, patients may need granulocyte-colony stimulating factor (G-CSF) to help boost the production of neutrophils. Infection causing febrile episodes is a medical emergency and treatment should be commenced within one hour of patients presenting with symptoms. Hospitals should have a neutropenic sepsis policy which allows treatment with broad-spectrum antibiotics to commence even when the source of infection is unclear.

Action:

Find out what the neutropenic sepsis policy for patients on systemic anti-cancer treatments (SACT) is in your hospital

Prevention and management of neutropenia

Although antibiotic prophylaxis may have a role in reducing infection rates, routine prophylactic use is usually only recommended for patients in the transplant setting or in very specific circumstances. In other settings, antibiotic prophylaxis is avoided as it increases the risk of inducing antibiotic resistance. There is currently very little evidence to promote the routine use of anti-fungal prophylaxis; however, anti-viral use is indicated for many patients especially if seropositive for herpes simplex virus and varicella zoster virus.

Other preventative measures to reduce the risk of infection should be considered for neutropenic patients. These include:

Vaccinations – the annual influenza vaccination is recommended for all myeloma patients and household contacts. Two doses of the pneumococcal vaccine are recommended and for those with chronic kidney disease, repeated every 5 years. Patients aged 50 and over should be offered the shingles vaccine in two doses, 8 weeks to 6 months apart. Following stem cell transplantation, it is recommended that childhood vaccinations are repeated. Myeloma patients should never receive any live attenuated vaccines and where possible avoid close contact with recipients of live vaccines.
Immunoglobulin replacement therapy – is commonplace in myeloma for patients who have repeated infections as a result of hypogammaglobulinaemia. Infusions are typically given on a monthly basis and may help reduce the risk of recurrent infections. NHS guidelines now allow earlier immunoglobulin replacement therapy in patients with myeloma who are receiving bispecific antibodies.

Nurses must inform, educate and support patients and their families about measures they can take to prevent bacterial, viral and fungal infections However, patients should also be aware that not all infections are preventable and they should always seek medical help if they have symptoms. All patients should be given details of who to contact for advice during the day and out of hours. This may be their local haematology unit, GP or NHS 111 depending on their individual situation. Patients on SACT should always contact their haematology team or out of hours service.

To help patients reduce their risk of infection, patient education should cover their understanding of:

When they are most vulnerable to infection e.g. during treatment and in the first few weeks post-transplant
Risks and signs of infection, and action to take in the event of a suspected infection
Importance of immediate reporting of infection symptoms
Importance of thorough personal hygiene, especially skin care for any open wounds and oral care/regular dental checkups to prevent oral mucositis.
Promotion of a clean environment; avoiding individuals with colds, flu or other infections such as measles, chickenpox and shingles; avoiding crowds and enclosed spaces such as busy buses or trains
Immunisation recommendations for working patients as part of workplace risk assessment

Some practical tips for nurses to pass onto patients include:

Maintain a high standard of personal hygiene and wash hands regularly and thoroughly. Carry hand sanitiser when away from home.
Store food correctly, wash fruit and vegetables, cook food thoroughly, keep raw and cooked meat separate, adhere to use-by dates
Have a working thermometer and report a raised temperature without delay
Take care when gardening and wear protective gloves
Wash hands after animal contact and avoid handling pet litter

Treatment for anaemia

Anaemia caused by myeloma disease may improve with anti-myeloma treatment but treatment-related anaemia should be treated. Some patients, especially those with renal impairment may benefit from a course of erythropoietin-stimulating agents (ESA). If persistent, discontinuation or dose reduction in treatment may be considered.

Alternatively, some patients require a blood transfusion to help correct the anaemia in the short-term, rather than stopping or reducing treatment. When this becomes appropriate will differ from patient to patient, depending on many factors such as when the patient becomes symptomatic of their anaemia and co-morbidities such as impaired cardiac function.

Prevention and management of anaemia

There are very few preventative strategies for anaemia but much can be done to help manage the fatigue which often accompanies anaemia.

Whilst it may seem contradictory, evidence shows that maintaining regular gentle exercise and making small adjustments to their life can minimise the effects of fatigue and improve an individual’s quality of life. Nurses should therefore provide this information to patients. Fatigue, like pain, is subjective. An awareness by nurses of this symptom and the mechanisms to reduce it can open up important dialogue between nurses and patients.

Fatigue is discussed in greater detail later on in this module.

Treatment for thrombocytopenia

As with neutropenia and anaemia, thrombocytopenia caused by the myeloma may improve with anti-myeloma treatment and treatment-related thrombocytopenia may be managed by dose modification or a temporary halt to treatment. Patients whose platelet count falls below (10 x 109/L) may benefit from a platelet transfusion.

Prevention and management of thrombocytopenia

There are no strategies to prevent thrombocytopenia but there are a number of measures to minimise the effects of bleeding in thrombocytopenic patients or reduce the risk of bleeding.

Nurses should inform patients and families of the signs of thrombocytopenia and encourage patients to:

Promptly report any bleeding, excessive bruising or petechial rash, including via 999 if severe.
Avoid the use of NSAIDs which have an anti-platelet effect such as aspirin, ibuprofen and naproxen unless instructed otherwise
Avoid activities e.g. contact sport, body piercing, tattooing that can result in bruising or bleeding
Exercise gentle oral care to avoid bleeding from the gums e.g. using a soft tooth brush and taking care when flossing. Patients should be encouraged to alert their dentist of their current medical situation to ensure appropriateness of intervention.
Use prophylactic stool softeners, if needed, to avoid constipation
Be careful not to cause cuts and wounds to the skin or blunt trauma to the body

Any invasive procedures should also be avoided if patients are thrombocytopenic. Where surgery is necessary, patients are always given a platelet transfusion beforehand if their levels are low.