Myeloma - symptoms and complications

What is fatigue?

Fatigue means feeling exceptionally tired, lethargic or exhausted – all, or most, of the time. It is a very common complication of myeloma and it can be difficult to manage fatigue associated with myeloma as it is often not improved by sleep or rest.

What causes fatigue in myeloma?

There are many potential causes of myeloma-related fatigue, with anaemia being the main cause. Other causes may include side-effects of treatments such as chemotherapy, Velcade™ or thalidomide, poor nutrition, pain and anxiety. It is important that doctors are aware that fatigue is a problem and the impact that it is having on the patient’s quality of life in order to assess any underlying cause and to treat it appropriately.

How is fatigue prevented and / or treated?

If fatigue is caused by anaemia due to the myeloma then this should improve once the myeloma is under control. Some patients may need treatment for the anaemia with blood transfusions or erythropoietin (a synthetic version of a naturally occurring hormone which stimulates red blood cell production).

If fatigue is caused by treatment then this should improve once treatment stops or the dose is modified.

Research shows that exercise is very effective in reducing fatigue. A regular exercise programme that is aerobic but not load-bearing, such as walking or swimming, may actually increase energy levels.

What causes pain in myeloma?

The principal cause of pain for myeloma patients is due to myeloma bone disease. Myeloma bone disease results in bones being broken down faster than is normal; this results in thinning and weakening of bones, which will then be prone to fractures.

Pain can also be caused by other factors; nerve damage (peripheral neuropathy) to the hands and feet, due to some treatments, can cause pain. Some infections such as urine and chest infections can also result in pain.

How is pain prevented and / or treated?

Bisphosphonates are a specific group of drugs that inhibit bone destruction in myeloma. They have been shown to reduce bone pain and the need for strong painkillers as well as reducing the likelihood of fractures.

There are many types of pain-killing drugs available and they come in a variety of formats from pills and liquids to sprays and tablets which dissolve under the tongue.

Radiotherapy can be a very effective short-term treatment for relieving myeloma bone pain in localised areas as well as relieving pressure on the nerves or spinal cord.

Many patients find that non-medical techniques such as gentle massage, relaxation therapy and hot / cold packs can often help.

It is very important that pain is assessed regularly and managed effectively. It may be possible to be referred to a pain specialist or the palliative care team. They are experts in managing complications and symptom control.

The aim of any pain relieving treatment is to provide continuous pain relief, whenever possible, with a minimum of unwanted side-effects.

What is myeloma bone disease?

Myeloma bone disease is the most frequent and often the most debilitating feature of myeloma. It causes pain and results in weakened bones that are very susceptible to fractures. Sometimes the bones can become so weak that they can break without undue force or injury – this is called a pathological fracture.

The areas most commonly affected include the bones of the middle or lower back, the hips and the rib cage. The long bones of the upper arms and legs can also be affected.

What causes myeloma bone disease?

Myeloma bone disease results from the myeloma cells in the bone morrow affecting the surrounding bone. Usually, the bones undergo a continuous cycle of bone remodelling where old bone is removed (or resorbed) by osteoclast cells and new bone is formed by osteoblast cells.

This process occurs in equilibrium so that the rate of old bone resorption is equal to the rate at which new bone is formed. When myeloma cells are present in the bone marrow, the myeloma cells stimulate the osteoclasts and reduce the number of osteoblasts. This results in a net loss of bone, i.e. more bone is resorbed than is formed.

How is myeloma bone disease prevented and / or treated?

Successful treatment to bring the myeloma under control will significantly reduce the likelihood of future bone damage. Treatment with bisphosphonates also helps to protect bones from future damage. Occasionally, surgery is required to stabilise a particularly weakened area or to repair a fracture.

What is hypercalcaemia?

Hypercalcaemia is a condition where there is a higher than normal level of calcium in the blood.

What causes hypercalcaemia?

Myeloma bone disease results in the increased breakdown of bones, which causes calcium to be released into the blood.

How is hypercalcaemia prevented and / or treated?

Hypercalcaemia is treated through treating the myeloma and myeloma bone disease. Bisphosphonates can be used to prevent / stop the breakdown of bone which causes the excess calcium in the blood.

What is anaemia?

Anaemia is a condition where there is a reduction of red blood cells in the blood. Red blood cells carry oxygen around the body in haemoglobin. It is the haemoglobin that is measured to determine if someone is anaemic or not. The normal haemoglobin for men is 13 to 17g per decilitre and for women it is 12 to 16g per decilitre.

As many as 75% of myeloma patients have some degree of anaemia when they are diagnosed. Anaemia is not always treated as it often improves once the myeloma has been brought under control. However, if someone is very symptomatic, and the anaemia is having a negative impact on quality of life, then treatment may be necessary.

What causes anaemia?

In myeloma, anaemia is often due to the fact that the myeloma cells stop the bone marrow cells producing enough red blood cells. Usually, the anaemia improves when the myeloma responds to treatment. However, some of the treatments for myeloma can temporarily cause a reduction in red blood cells, although this should improve once treatment is finished.

How is anaemia prevented and / or treated?

Initial treatment for anaemia is usually to give a blood transfusion(s) but an alternative is to give injections of a synthetic version of a naturally occurring hormone erythropoietin (EPO), which stimulates red blood cell production.

Does myeloma damage the kidneys?

Kidney problems can occur in myeloma for a variety of reasons. The abnormal protein produced by myeloma cells can damage the kidneys. Other complications of myeloma, such as dehydration and hypercalcaemia, as well as some of the drugs used to treat myeloma and its complications, can cause kidney damage.

What causes kidney damage?

It is quite common for myeloma patients to have some kidney damage at diagnosis or for it to occur at later stages. The kidneys can be overwhelmed by the excessive levels of abnormal protein (paraprotein) produced by the myeloma, particularly the light chain part of the paraprotein structure, which can block the very fine tubules within the kidney. High calcium levels produced when myeloma affects the bones can also affect kidney function as can some of the treatments for myeloma or its complications.

What are the symptoms of kidney damage?

Kidney disease can cause fluid retention resulting in swelling of the legs; excess fluid on the lungs can make breathing more laboured. There may be reduced urine output.

How is kidney damage prevented and / or treated?

In many patients, kidney function recovers with effective treatment for the myeloma. If the kidneys are going to recover they generally do so within three or four months of treatment beginning. However, in a small number of patients, kidney damage is severe and permanent and regular dialysis treatment is required.

It is important for myeloma patients to drink as much water as they can as this helps to keep the kidneys well flushed and in good working order.

What is mucositis?

Mucositis describes damage to the cells in the lining of the mouth and an increase in susceptibility to pain, ulcers, and infection of this area during treatment with chemotherapy.

What causes mucositis?

Chemotherapy works by killing the body’s rapidly growing cells, i.e. myeloma cells. Unfortunately, however, it also kills other healthy cells which divide rapidly such as the cells that line the mouth and gastrointestinal tract.

How is mucositis prevented and / or treated?

There are a number of simple things that can be done to help reduce mouth problems. These include drinking plenty of fluids, brushing your teeth regularly with a soft tooth brush, and rinsing your mouth with water after meals. Dentures, if worn, need to be well-fitting and cleaned thoroughly between meals. There are several drugs available both to treat and prevent mucositis.

What is peripheral neuropathy?

Peripheral neuropathy is the term used to describe damage to the nerves that make up the peripheral nervous system. The nerves that are most commonly affected are those of the hands and feet.

What causes peripheral neuropathy?

Peripheral neuropathy can be caused by some of the treatments for myeloma such as thalidomide, Velcade™ and Revlimid™. However, in some cases it can be caused by the myeloma itself.

How is peripheral neuropathy prevented and / or treated?

At present, research has not identified a way of effectively treating or curing peripheral neuropathy. The key to its management lies in eliminating or reducing the cause, whilst treating the symptoms that occur.

If neuropathy is caused by treatment, lowering the dose of the drug thought to be responsible, or stopping it for a period of time, may help.

Neuropathy can be reversed in many cases once these drugs are stopped, although a reduction in symptoms may not happen immediately and is not guaranteed. Some patients may need to stop the treatment permanently to avoid long-term damage.

If neuropathy is caused by myeloma then once it has been brought under control by treatment, symptoms should improve.

What is nausea?

In myeloma, nausea can be a common symptom of treatment or of the myeloma itself. Nausea is a feeling of unease and discomfort in the upper stomach with an urge to vomit.

What causes nausea?

Nausea is controlled by the ‘vomiting centre’ in the brain. Nausea occurs when certain signals are sent to the brain, which triggers feelings of nausea and / or vomiting.
Many of the drugs used to treat myeloma can cause nausea and / or vomiting as a side-effect. However, other drugs such as painkillers and treatments such as radiotherapy can also cause nausea and / or vomiting.

Nausea and vomiting can also be affected by psychological and emotional factors. There are many aspects of your myeloma and the effects it will have on you and your family that can cause feelings of anxiety. This can cause nausea and / or vomiting. Also, if you have previously been affected by nausea and vomiting during treatment, you may anticipate that you will experience the same symptoms again. Thinking like this can induce nausea. This common phenomenon is called anticipatory nausea.

Pain is a common symptom of myeloma, especially pain due to myeloma bone disease. If pain is severe it can cause nausea and / or vomiting.

How is nausea prevented and / or treated?

Nausea and vomiting can often be prevented / reduced by treating the cause. For example, painkillers can be used to manage pain effectively and distraction techniques can be used to take your mind off of thinking about feeling sick.

However, as mentioned, nausea and vomiting can also be due to the treatment of myeloma and its complications. Therefore, other methods have to be used to help prevent / reduce nausea. Anti-emetic (anti-sickness) drugs can be used to prevent / reduce nausea. If you continue to feel nauseous and are vomiting, it is important to tell your doctor or nurse.

What is constipation?

Constipation is usually diagnosed when your bowels are moving less than three times per week. When you are constipated your bowel movements may be dry, hard and painful to pass.

It is important to know what your normal bowel pattern is, as constipation can mean different things to different people; some people have bowel movements two or three times a day whereas for others, it may be normal to only have three or four bowel movements per week.

What are the causes of constipation in myeloma?

The causes of constipation in myeloma are varied and can include:

• Side-effects of treatment
• Poor diet / loss of appetite
• Dehydration
• Hypercalcaemia
• Lack of exercise / poor mobility
• Stress, anxiety and depression
• Change in routine

How is constipation prevented and / or treated?

In addition to the prescribed medications that are available for relieving constipation there are many effective natural and non-prescription remedies that you can buy over the counter.

Therefore, when you initially develop constipation you may benefit from first approaching your local pharmacist for treatment and practical advice on self-management. However, if your constipation persists then it will be necessary to consult your doctor.

What is osteonecrosis of the jaw?

Osteonecrosis of the jaw (ONJ) is a rare side-effect associated with bisphosphonate use. Symptoms of ONJ include poor or non-healing of a tooth socket after extraction, an area of exposed bone in the mouth, swelling and pain, and a heavy or numb feeling in the jaw.

What causes ONJ?

ONJ is mostly associated with the intravenous bisphosphonates such as Aredia® or Zometa®, but steroids and chemotherapy can also contribute. It appears to be more common following invasive dental work. The problem has only become apparent during the last five to six years and it is not yet known exactly why or how often it occurs.

How is ONJ prevented and / or treated?

It is recommended that patients who receive an intravenous bisphosphonate be examined by a dentist and have any necessary dental work done prior to commencing treatment. If any dental treatment is necessary while a patient is receiving a bisphosphonate it should be discontinued before work begins and for a short time after.

Treatment of ONJ may involve antibiotics and painkillers. Sometimes a small procedure may be done to remove some of the dead tissue or bone from the affected area.