Successful autologous peripheral blood stem cell transplantation in a Jehovah's Witness with multiple myeloma: review of literature and recommendations for high-dose chemotherapy without support of allogeneic blood products

What's Old is New: The Past, Present and Future Role of Thalidomide in the Modern-Day Management of Multiple Myeloma

Immunomodulatory drugs (IMiDs) have become an integral part of therapy for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM). IMiDs bind to cereblon, leading to the degradation of proteins involved in B-cell survival and proliferation. Thalidomide, a first-generation IMiD, has little to no myelosuppressive potential, negligible renal clearance, and long-proven anti-myeloma activity. However, thalidomide's adverse effects (e.g., somnolence, constipation, and peripheral neuropathy) and the advent of more potent therapeutic options has led to the drug being less frequently used in many countries, including the US and Canada. Newer-generation IMiDs, such as lenalidomide and pomalidomide, are utilized far more frequently. In numerous previous trials, salvage therapy with thalidomide (50-200 mg/day) plus corticosteroids (with or without selected cytotoxic or targeted agents) has been shown to be effective and well-tolerated in the RRMM setting. Hence, thalidomide-based regimens remain important alternatives for heavily pretreated patients, especially for those who have no access to novel therapies and/or are not eligible for their use (due to renal failure, high-grade myelosuppression, or significant comorbidities). Ongoing and future trials may provide further insights into the current role of thalidomide, especially by comparing thalidomide-containing regimens with protocols based on newer-generation IMiDs and by investigating thalidomide's association with novel therapies (e.g., antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T cells).

Italian daily platelet transfusion practice for haematological patients undergoing high dose chemotherapy with or without stem cell transplantation: a survey by the GIMEMA Haemostasis and Thrombosis Working Party

BACKGROUND

Following high-dose chemotherapy/bone marrow transplantation, patients are routinely, prophylactically transfused with platelet concentrates (PC) if they have a platelet count ≤10×10⁹/L or higher in the presence of risk factors for bleeding. However, whether such transfusions are necessary in clinically stable patients with no bleeding, or whether a therapeutic transfusion strategy could be sufficient and safe, is still debated.

MATERIALS AND METHODS

The GIMEMA Haemostasis and Thrombosis Working Party sent a questionnaire to Italian haematology departments to survey several aspects of daily platelet transfusion practice, such as the cut-off platelet count for transfusion, the evaluation of refractoriness and the type of PC administered.

RESULTS

The questionnaire was answered by 18 out of 31 centres (58%). A total of 23,162 PC were transfused in 2,396 patients in 2013. The vast majority of centres (95%) transfused PC according to Italian and international guidelines; only a few transfused always at platelet counts ≤20×10⁹/L. The broad agreement on platelet count cut-off for transfusion (≤10×10⁹/L) was not confirmed when the World Health Organization (WHO) bleeding score was considered: only a third of centres (33%) used transfusions as recommended when the bleeding grade was ≥2. Platelet refractoriness was poorly monitored and most centres (89%) evaluated, mostly empirically (67%), response to transfusion only 24 hours later. Thirty percent of centres transfused platelets in asymptomatic refractory patients.

DISCUSSION

Although most Italian haematology departments transfuse PC according to Italian and international guidelines, our survey shows that in routine daily practice physicians do not comply closely with the WHO recommendations on platelet transfusions and monitoring platelet refractoriness. This causes excessive platelet transfusions, with a resulting increase of costs and waste of public health resources.