A global panel of experts convened by the International Myeloma Society has published consensus guidelines and recommendations for the prevention of infection in multiple myeloma, which remains the leading cause of morbidity and mortality in patients despite advances in treatment response.
The panel was asked to review existing literature and current guidelines from the Centers for Disease Control and Prevention, The Infectious Disease Society of America, and the National Comprehensive Cancer Network (NCCN), discuss topics related to infection risks and prevention of infectious complications in the context of emerging therapies, and provide recommendations for preventing such complications.
Broadly speaking, they concluded that the key to reducing the burden of infectious complications in this patient group is “an individualised treatment plan adapted by risk after comprehensive staging at diagnosis and relapse.”
The panel recommended optimising dose intensity in patients considered at high risk of severe infection and of clinically significant comorbidities, and considering the state of immunosuppression when treating a relapsed patient who has had multiple previous lines of therapy.
Key strategies for prevention of infection include ensuring that patients are vaccinated against common pathogens, with particular attention paid to the timing of vaccination, and also educating both patient and their carers about reducing exposure to sources of pathogens.
“Furthermore, we recommend risk-adapted antimicrobial prophylaxis and consideration of immunoglobulin replacement, and possibly myeloid growth factor support, in a small subset of patients,” the authors noted, and also suggested “careful surveillance during highly immunosuppressive therapies and after autologous HSCT” as this could help anticipate the chance and type of infection.
Outlining key features and recommendations in a paper published in The Lancet Haematology, the researchers highlighted that the periods of highest infectious risk are during the first three months following diagnosis and when treating relapsed or refractory multiple myeloma.
During such periods, physicians could consider antibacterial prophylaxis with levofloxacin, or acyclovir for patients testing seropositive for herpes simplex virus and varicella zoster virus. The researchers also suggest acyclovir prophylaxis for patients receiving proteasome inhibitors or targeted monoclonal antibodies, specifically CD38-directed monoclonal antibodies.
Trimethoprim-sulfamethoxazole should be reserved for patients at risk of Pneumocystis jiroveccii pneumonia, such as those with relapsed and refractory myeloma or in receipt of high doses of dexamethasone.
Patients with multiple myeloma should be immunised with inactivated influenza vaccine annually, and an inactivated S pneumoniae vaccine every five years, and the group stressed that “protection by vaccination is best achieved when vaccines are given in early disease stages (eg, monoclonal gammopathy of undetermined significance or smouldering multiple myeloma), before the initiation of treatment or when response is reached”.
It was also noted that single-agent lenalidomide boosts response to vaccination in multiple myeloma patients, as long as dexamethasone is not given concurrently, and that responses to immunisation after receiving novel agents such as monoclonal antibodies, panobinostat, and selinexor “are yet to be established”.
The panel recommended revaccination of patients with recombinant zoster vaccine vaccination 6-24 months after autologous haematopoietic stem-cell transplantation (HSCT), and extension of the recombinant zoster vaccine to all patients with multiple myeloma.
They concluded that the general principles and recommendations provided offer physicians “a template from which an individualised patient-specific plan can be derived”.