Multiple Myeloma

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Treating Multiple Myeloma TOPICS

Chemotherapy and other drugs for multiple myeloma

Chemotherapy (chemo) is the use of drugs to destroy or control cancer cells. These drugs can be taken by mouth or given in a vein or a muscle. They enter the bloodstream and reach all areas of the body, making this treatment useful for cancers such as multiple myeloma that often spread widely.

Many different types of drugs are used to treat multiple myeloma.

Traditional chemo

Chemo drugs that may be used to treat multiple myeloma include

  • Melphalan
  • Vincristine (Oncovin)
  • Cyclophosphamide (Cytoxan)
  • Etoposide (VP-16)
  • Doxorubicin (Adriamycin)
  • Liposomal doxorubicin (Doxil)
  • Bendamustine (Treanda)

Combinations of these drugs are more effective than any single drug. Often these drugs are combined with other types of drugs like corticosteroids or immunomodulating agents (drugs that will change the patient’s immune response).

Chemo side effects

Chemo drugs kill cancer cells but also can damage normal cells. They are given carefully to avoid or reduce the side effects of chemotherapy. These side effects depend on the type and dose of drugs given and the length of time they are taken. Common side effects of chemotherapy include:

  • Hair loss
  • Mouth sores
  • Loss of appetite
  • Nausea and vomiting
  • Low blood counts

Chemotherapy often leads to low blood counts, which can cause the following:

  • Increased risk of serious infection (from low white blood cell counts)
  • Easy bruising or bleeding (from low blood platelets or thrombocytopenia)
  • Feeling excessively tired or short of breath (from low red blood cells or anemia).

Most side effects are temporary and go away after treatment is finished.

If you have side effects, your cancer care team can suggest steps to ease them. For example, drugs can be given along with the chemo to prevent or reduce nausea and vomiting.

In addition to these temporary side effects, some chemo drugs can permanently damage certain organs such as the heart or kidneys. The possible risks of these drugs are carefully balanced against their benefits, and the function of these organs is carefully monitored during treatment. If serious organ damage occurs, the drug that caused it is stopped and replaced with another.


Corticosteroids, such as dexamethasone and prednisone, are an important part of the treatment of multiple myeloma. They can be used alone or combined with other drugs as a part of treatment. Corticosteroids are also used to help decrease the nausea and vomiting that chemo may cause.

Common side effects of these drugs include

  • High blood sugar
  • Increased appetite and weight gain
  • Problems sleeping
  • Changes in mood (some people become irritable or “hyper”)

When used for a long time, corticosteroids also suppress the immune system. This leads to an increased risk of serious infections. They can also weaken bones.

Most of these side effects go away over time after the drug is stopped.

Immunomodulating agents

The way immunomodulating agents affect the immune system isn’t entirely clear. Three immunomodulating agents are used to treat multiple myeloma. The first of these drugs to be developed, thalidomide, caused severe birth defects when taken during pregnancy. Because the other immunomodulating agents are related to thalidomide, there’s concern that they could also cause birth defects. That’s why all of these drugs can only be obtained through a special program run by the drug company that makes them.

Because these drugs can increase the risk of serious blood clots, they are often given along with aspirin or a blood thinner.

Thalidomide (Thalomid) was first used decades ago as a sedative and as a treatment for morning sickness in pregnant women. When it was found to cause birth defects, it was taken off the market. Later, it became available again as a treatment for multiple myeloma. Side effects of thalidomide can include drowsiness, fatigue, severe constipation, and painful nerve damage (neuropathy). The neuropathy can be severe, and might not go away after the drug is stopped. There is also an increased risk of serious blood clots that start in the leg and can travel to the lungs.

Lenalidomide (Revlimid) is a similar to thalidomide. It works well in treating multiple myeloma. The most common side effects of lenalidomide are thrombocytopenia (low platelets) and low white blood cell counts. It can also cause painful nerve damage. The risk of blood clots is not as high as that seen with thalidomide, but it is still increased.

Pomalidomide (Pomalyst) is also related to thalidomide and is used to treat multiple myeloma. Some common side effects include low red blood cell counts (anemia) and low white blood cell counts. The risk of nerve damage is not as severe as it is with the other immunomodulating drugs, but it’s also linked to an increased risk of blood clots.

Proteasome inhibitors

Proteasome inhibitors work by stopping enzyme complexes (proteasomes) in cells from breaking down proteins important for keeping cell division under control. They appear to affect tumor cells more than normal cells, but they are not without side effects.

Bortezomib (Velcade) was the first of this type of drug to be approved, and it’s often used to treat multiple myeloma. It may be especially helpful in treating myeloma patients with kidney problems. It’s injected into a vein (IV) or under the skin, once or twice a week.

Common side effects of this drug include nausea and vomiting, tiredness, diarrhea, constipation, fever, decreased appetite, and lowered blood counts. The platelet count (which can cause easier bruising and bleeding) and the white blood cell count (which can increase the risk of serious infection) are most often affected. Bortezomib can also cause nerve damage (peripheral neuropathy) that can lead to problems with numbness, tingling, or even pain in the hands and feet. Some patients develop shingles (herpes zoster) while taking this drug. To help prevent this, your doctor may have you take an anti-viral medicine (like acyclovir) while you take bortezomib.

Carfilzomib (Kyprolis) is a newer proteasome inhibitor that can be used to treat multiple myeloma in patients who have already been treated with bortezomib and an immunomodulating agent. It’s given as an injection into a vein (IV), often in a 4 week cycle. To prevent problems like allergic reactions during the infusion, the steroid drug dexamethasone is often given before each dose in the first cycle.

Common side effects include tiredness, nausea and vomiting, diarrhea, shortness of breath, fever, and low blood counts. The blood counts most often affected are the platelet count (which can cause easier bruising and bleeding) and the red blood cell count (which can lead to tiredness, shortness of breath, and being pale). People on this drug can also have more serious problems, such as pneumonia, heart problems, and kidney or liver failure.

Ixazomib (Ninlaro) is a proteasome inhibitor that is taken by mouth as a capsule, typically once a week for 3 weeks, followed by a week off. This drug is usually used after other drugs have been tried.

Common side effects of this drug include nausea and vomiting, diarrhea, constipation, rash, swelling in the hands or feet, back pain, and a lowered blood platelet count (which can cause easier bruising and bleeding). This drug can also cause nerve damage (peripheral neuropathy) that can lead to problems with numbness, tingling, or even pain in the hands and feet.

Histone deacetylase (HDAC) inhibitors

HDAC inhibitors are a group of drugs that can affect which genes are active inside cells. They do this by interacting with proteins in chromosomes called histones.

Panobinostat (Farydak) is an HDAC inhibitor that can be used to treat patients who have already been treated with bortezomib and an immunomodulating agent. It is taken as a capsule, typically 3 times a week for 2 weeks, followed by a week off. This cycle is then repeated.

Common side effects include diarrhea (which can be severe), feeling tired, nausea, vomiting, loss of appetite, swelling in the arms or legs, fever, and weakness. This drug can also affect blood cell counts and the levels of certain minerals in the blood. Less common but more serious side effects can include bleeding inside the body, liver damage, and changes in heart rhythm, which can sometimes be life threatening.

Monoclonal antibodies

Antibodies are proteins made by the body’s immune system to help fight infections. Man-made versions, called monoclonal antibodies, can be designed to attack a specific target, such as a substance on the surface of myeloma cells.

Daratumumab (Darzalex) is a monoclonal antibody that attaches to the CD38 protein, which is found on myeloma cells. This is thought to both kill the cells directly and to help the immune system attack the cells. This drug is used mainly in patients who have already had several other treatments for their myeloma. It’s given as an injection into a vein (IV).

This drug can cause a reaction in some people while it is being given or within a few hours afterward, which can sometimes be severe. Symptoms can include coughing, wheezing, trouble breathing, tightness in the throat, a runny or stuffy nose, feeling dizzy or lightheaded, headache, rash, and nausea.

Other side effects can include fatigue, nausea, back pain, fever, and cough. This drug can also lower blood cell counts, which can increase the risk of infections and bleeding or bruising.

Using these drugs together to treat multiple myeloma

Although a single drug may be used to treat multiple myeloma, more often different kinds of drugs are used in combination. For example:

  • Melphalan and prednisone (MP), with or without thalidomide or bortezomib
  • Vincristine, doxorubicin (Adriamycin), and dexamethasone (called VAD)
  • Thalidomide (or lenalidomide) and dexamethasone
  • Bortezomib, doxorubicin, and dexamethasone,
  • Bortezomib, dexamethasone, and thalidomide (or lenalidomide)
  • Liposomal doxorubicin, vincristine, dexamethasone
  • Carfilzomib, lenalidomide, and dexamethasone
  • Dexamethasone, cyclophosphamide, etoposide, and cisplatin (called DCEP)
  • Dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide (called DT-PACE), with or without bortezomib
  • Panobinostat, bortezomib, and dexamethasone
  • Ixazomib, lenalidomide, and dexamethasone

The choice and dose of drug therapy depend on many factors, including the stage of the cancer and the age and kidney function of the patient. If a stem cell transplant is planned, most doctors avoid using certain drugs, like melphalan, that can damage the bone marrow.

For more information about chemotherapy and its side effects, see A Guide to Chemotherapy.

Last Medical Review: 05/22/2014
Last Revised: 11/20/2015