Integrating novel agents into multiple myeloma treatment - current status in Switzerland and treatment recommendations

The treatment of multiple myeloma has undergone significant changes in the recent past. The arrival of novel agents, especially thalidomide, bortezomib and lenalidomide, has expanded treatment options and patient outcomes are improving significantly. This article summarises the discussions of an expert meeting which was held to debate current treatment practices for multiple myeloma in Switzerland concerning the role of the novel agents and to provide recommendations for their use in different treatment stages based on currently available clinical data. Novel agent combinations for the treatment of newly diagnosed, as well as relapsed multiple myeloma are examined. In addition, the role of novel agents in patients with cytogenetic abnormalities and renal impairment, as well as the management of the most frequent side effects of the novel agents are discussed. The aim of this article is to assist in treatment decisions in daily clinical practice to achieve the best possible outcome for patients with multiple myeloma.

Suppression and recovery of adrenal response after short-term, high-dose glucocorticoid treatment

BACKGROUND

Suppression of the adrenal response is an unpredictable consequence of glucocorticoid treatment. To investigate the kinetics of the adrenal response after short-term, high-dose glucocorticoid treatment, we measured the adrenal response to the low-dose (1 microg) corticotropin stimulation test.

METHODS

We studied 75 patients who received the equivalent of at least 25 mg prednisone daily for between 5 days and 30 days. After discontinuation of glucocorticoid treatment, 1 microg corticotropin was administered intravenously, and stimulated plasma cortisol concentrations were measured 30 min later. In patients with a suppressed response to 1 microg corticotropin, the test was repeated until stimulated plasma cortisol concentrations reached the normal range.

FINDINGS

The adrenal response to 1 microg corticotropin was suppressed in 34 patients and normal in 41. Subsequent low-dose corticotropin tests showed a steady recovery of the adrenal response within 14 days. In two patients, the adrenal response remained suppressed for several months. There was no correlation between plasma cortisol concentrations and the duration or dose of glucocorticoid treatment.

INTERPRETATION

Suppression of the adrenal response is common after short-term, high-dose glucocorticoid treatment. The low-dose corticotropin test is a sensitive and simple test to assess the adrenal response after such treatment.

Can magnesium sulfate reduce the risk of cerebral injury after perinatal asphyxia?

Hypoxia-ischemia produces brain damage by processes that continue for many hours after reoxygenation/reperfusion. This provides a window of opportunity for therapy aimed at preventing further loss of brain cells. Sulfate magnesium can prevent posthypoxic brain injury by blocking glutamate receptors within the calcium (Ca++) ion channel. We used sulfate magnesium in nine newborn infant after perinatal hypoxia. We investigated the brain damage, by ultrasound examination, on third day, in first, second and third week, and third, sixth month of life. We have estimated the neurological development in the first week of life and third and twelfth month of life. We did not find deviations in ultrasound examination. We did not observe convulsions. We did not observe any side effect of this therapy. The examination at 1 of year of life in all of children was correct.

Long-term protection after stopping venom immunotherapy: results of re-stings in 200 patients

BACKGROUND

Venom immunotherapy (VIT) protects most patients allergic to Hymenoptera stings while booster injections are continued. Few data on long-term protection after discontinuation of treatment are available.

OBJECTIVE

We sought to investigate protection from re-stings over a prolonged period after stopping VIT.

METHODS

Re-sting data were obtained from 200 of 322 patients in whom VIT had been stopped between 1988 and 1992 after a duration of at least 3 years. The 25 (12.5%) patients who again developed systemic allergic reactions were compared with 50 matched patients without re-sting reactions. Clinical data and diagnostic parameters (i.e., skin sensitivity and specific IgE and IgG) were studied.

RESULTS

Of the 25 patients who had re-sting reactions, 19 had been treated with bee venom (relapse rate, 15.8%), and six had been treated with Vespula venom (relapse rate, 7.5%). About half of the re-sting reactions occurred on the first resting after stopping VIT. Most of these reactions were mild, whereas the majority of reactions occurring after repeated re-stings were severe. When re-sting reactions were related to the total re-stings per year, an accumulation of sting reactions was observed in years 3 to 5 after stopping VIT. Patients with re-sting reactions had been receiving VIT for a significantly shorter duration (43.35 months) than those with continued protection (54.65 months) (p < 0.01). Of the diagnostic parameters, only a negative intracutaneous skin test at 10(-3) gm/L predicted long-term protection reliably.

CONCLUSION

Venom immunotherapy of 3 to 5 years duration induces long-term protection in most patients. In rare occasions severe re-sting reactions may, however, occur, especially after repeated re-stings.

Clinical and immunological condition of newborns of mothers treated for recurrent spontaneous abortions with paternal lymphocytes immunization

OBJECTIVE

The aim of this study was to evaluate the clinical condition at birth and some laboratory parameters in newborns of mothers treated for recurrent spontaneous abortion (RSA) of unknown etiology with paternal lymphocytes immunization.

STUDY DESIGN

The study comprised 104 newborns delivered by 102 women with RSA, who underwent alloimmunization and 90 randomly chosen control newborns. The following parameters were analysed in two groups of newborns: general condition at birth, physical development, course of adaptation period, values of hematological and immunological (percentage of CD3, CD4, CD8, CD19 and CD3/CD25 lymphocytes, chemiluminescence of neutrophils at rest and stimulated with opsonized zymosane) parameters in umbilical arterial blood.

RESULTS

No statistically significant differences were noted between the two groups of newborns as to the duration of pregnancy, birth weight, general condition at birth, occurrence of complications in the adaptation period and values of studied hematological and immunological parameters.

CONCLUSION

These results suggest that immunization with paternal lymphocytes in women with RSA of unknown etiology not only creates better prognosis for the outcome of the pregnancy, but is also safe for the fetus and the newborn.