Management of patients with multiple myeloma in the era of COVID-19 pandemic: a consensus paper from the European Myeloma Network (EMN)

Abstract

Patients with multiple myeloma (MM) seem to be at increased risk for more severe COVID-19 infection and associated complications due to their immunocompromised state, the older age and comorbidities. The European Myeloma Network has provided an expert consensus statement in order to guide therapeutic decisions in the era of the COVID-19 pandemic. Patient education for personal hygiene and social distancing measures, along with treatment individualization, telemedicine and continuous surveillance for early diagnosis of COVID-19 are essential. In countries or local communities where COVID-19 infection is widely spread, MM patients should have a PCR test of nasopharyngeal swab for SARS-CoV-2 before hospital admission, starting a new treatment line, cell apheresis or ASCT in order to avoid ward or community spread and infections. Oral agent-based regimens should be considered, especially for the elderly and frail patients with standard risk disease, whereas de-intensified regimens for dexamethasone, bortezomib, carfilzomib and daratumumab should be used based on patient risk and response. Treatment initiation should not be postponed for patients with end organ damage, myeloma emergencies and aggressive relapses. Autologous (and especially allogeneic) transplantation should be delayed and extended induction should be administered, especially in standard risk patients and those with adequate MM response to induction. Watchful waiting should be considered for standard risk relapsed patients with low tumor burden, and slow biochemical relapses. The conduction of clinical trials should continue with appropriate adaptations to the current circumstances. Patients with MM and symptomatic COVID-19 disease should interrupt anti-myeloma treatment until recovery. For patients with positive PCR test for SARS-CoV-2, but with no symptoms for COVID-19, a 14-day quarantine should be considered if myeloma-related events allow the delay of treatment. The need for surveillance for drug interactions due to polypharmacy is highlighted. The participation in international COVID-19 cancer registries is greatly encouraged.

Myeloma care adaptations in the UK during SARS‐CoV‐2 pandemic: Challenges and measurable outcomes

“…If stem cell harvest cannot be delayed, it should be performed at the end of induction, 5,9 or after 4 cycles in the case of LenDex, whilst transplant decision is reviewed by the MDT. The filgrastim‐only priming strategy can be employed during the pandemic in order to reduce the risk of immunosuppression associated with high dose cyclophosphamide 5,9 . However, the use of salvage plerixafor may be needed in some cases, 5,9 which, in turn, will require hospital visits.…”

“…The filgrastim‐only priming strategy can be employed during the pandemic in order to reduce the risk of immunosuppression associated with high dose cyclophosphamide 5,9 . However, the use of salvage plerixafor may be needed in some cases, 5,9 which, in turn, will require hospital visits.…”

“…The optimal uses of prophylactic antivirals, pneumocystis jirovecii (PCP) prophylaxis, antibacterial prophylaxis with levofloxacin (for 12 weeks in NDMM) and anti‐thrombotic agents (with IMiDs) are recommended during the pandemic, in addition to prophylactic filgrastim in patients with a history of recurrent neutropenia, and erythropoiesis‐stimulating agents in anaemic patients in order to prevent the need for blood transfusions and the associated hospital visits 5,9 …”

“…Frequency reduction of bisphosphonates (eg, zoledronic) from monthly to 3 monthly 5,9 especially in NDMM patients who achieved a significant myeloma response, will reduce hospital visits and the associated risk of COVID‐19 transmission. However, this strategy may not provide patients with optimal protection from future skeletal‐related events (SREs) compared to those who received monthly antiresorptive therapy for a minimum of 2 years.…”

“…However, it is not currently approved in the UK to treat myeloma patients. When it becomes available, it can prevent hospital visits if home administration facilities are available or where patients are educated about self‐administration 9 …”