Recommendations for the management of patients with multiple myeloma in the United States during the COVID-19 pandemic

This article has kindly been put together by Deepu Madduri, Mount Sinai Hospital, New York, US, and features recommendations on the treatment of patients with multiple myeloma (MM) in the United States during the SARS-CoV-2 pandemic.

Introduction

Cancer patients have a known higher COVID-19 complication rate than patients without cancer (read more). Patients with MM tend to be older, have a decreased immunity — demonstrated by the fact the most common cause of morbidity/mortality is infection — and, if they are receiving chemotherapy or have other comorbidities, e.g. cardiac or pulmonary history or cardiac amyloidosis, may be at an even higher risk of infections such as SARS-CoV-2. For each patient, therefore, it is important to be certain that the benefit of outpatient treatment (specifically chemotherapy) exceeds the risk of infection during transit, nosocomial acquisition of the virus, or transmission to outpatient staff. This risk/benefit analysis may change with the evolving nature of SARS-CoV-2 transmission patterns in each area.

At Mount Sinai Hospital, when adapting a patient’s care plan, we are using the phrase “COVID-19 transition plan” to ensure that when our outstanding nurses are handling a high volume of patient calls, they can quickly search in Elderly Pharmaceutical Insurance Coverage (EPIC) charts for the plan.

Guidelines that are being used at Mount Sinai Hospital are listed below, but everything must be considered on an individual patient basis:

• Avoid elective procedures, such as stem cell harvest and stem cell transplant
  • The American Society for Transplantation and Cellular Therapy (ASTCT) recently released guidelines, which you can find here
• Avoid routine restaging, such as bone marrow biopsies and scans
  • Bone marrow biopsies and scans should only be completed if the result will lead to an immediate change in patient management
• Patients with newly diagnosed MM or relapsed MM with recent progression:
  • If cytopenias or chemistries need to be monitored, or parenteral drugs are required, keep outpatient visits going
  • If labs are stable and it is possible, switch to all oral drug regimen (e.g. dexamethasone or prednisone, ixazomib, immunomodulatory drugs [IMiDs®], cyclophosphamide) and cancel outpatient visits
  • Monitor the patient’s signs and symptoms or concerns via telemedicine or phone call if possible
• Patients in remission with > partial response with a consistent downtrend in MM labs:
  • If parenteral chemotherapy is the only way to control disease, and the COVID-19 situation permits, continue outpatient treatment but use clinical judgement
  • If at all possible, switch the patient to all oral chemotherapy regimen and cancel outpatient visits
• Intravenous (IV) immunoglobulin (Ig) is currently only indicated in patients with a history of recurrent bacterial infections and hypogammaglobulinemia (where IgG is numerically low or in patients with IgG MM where most IgG is monoclonal). If the only reason a patient would attend an outpatient appointment is for IV Ig, then
  • Skip one dose if IgG levels are ~700 or higher
    • The half-life of monoclonal antibodies is long, and dosing can be revisited every 3–4 weeks based on the COVID-19 status
  • If IgG < 700, continue monthly IV Ig unless the patient does not have a history of recurrent infections and was only started for numerical hypogammaglobulinemia —discuss with treating physician
  • Consider giving IV Ig at home if insurance allows and there are no protracted healthcare access issues, but this will have to be on a case-by-case basis and will need discussion and help of a social worker
• If laboratory testing is required, consider using a local blood center (e.g. Quest, Labcorp, or local oncology center) and mailer kit for patients that live further away
  • If uncertain about the need for an outpatient visit, consider a telephone/video call first to assess the clinical status
• Women who require a prescription for IMiDs:
  • If the woman is of child-bearing age and requires a pregnancy test, the patient can call the respective pharmaceutical company customer care and request home pregnancy tests. These will be mailed to the patient by the company and once the patient does the home test, they can call us with the result; this can be documented in the chart so that a prescription can be called in
  • If the woman is not of childbearing potential, up to 56 tabs of IMiDs at one time can be requested from the pharmaceutical company
• For patients on oral dexamethasone at home, instruct patients to check their temperature on the morning of taking dexamethasone to ensure fevers are not being masked. Remind patients to call if they have fever/upper respiratory tract symptoms or if they have had known exposure to SARS-CoV-2
  • If the patient is asymptomatic but has had known exposure to SARS-CoV-2, consider holding any oral chemotherapy, especially steroids, for at least seven days to ensure a clear clinical picture
• For patients being switched to oral chemotherapy, aim to have a family member present if possible and ask the patient to read back the proposed new oral chemotherapy regimen to avoid dosing errors
  • If the patient has limited health literacy, ask the patient to call back once the oral drugs have arrived to confirm the dosing and schedule once the drugs are in-hand
  • Consider instructing the patient to take oral steroids and prescribe an oral anti-emetic as pre-medications before taking ixazomib and/or oral cyclophosphamide at home
    • Please give prescription for anti-nausea and/or anti-diarrheal medication as needed
  • For fragile patients, oral cyclophosphamide may be better tolerated as once daily (QD) or twice daily (BID) instead of once weekly
• For patients needing to come to outpatient clinics, encourage private transportation and enlist social workers if necessary. Encourage patients to call if they have any symptoms of COVID-19 prior to scheduled outpatient appointments