# Treatment options for multiple myeloma
The treatment of multiple myeloma has changed dramatically over the past years. Where chemotherapy and stem cell transplantation were once the cornerstones, many more options are now available. The choice depends on your age, overall health, disease risk profile, and how well your body responds to previous treatments.
Chemotherapy and proteasome inhibitors
Proteasome inhibitors have been a strong pillar in treatment for about two decades. They work by blocking a specific enzyme (the proteasome) in cancer cells, causing harmful proteins to accumulate and the cell to die. They are often combined with other medicines.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Proteasome inhibitors such as bortezomib are used in many treatment regimens, especially in combination with corticosteroids and immunomodulatory medicines. Known side effects are nerve pain in hands and feet, diarrhea, fatigue and increased infection risk. With intravenous administration, reactions at the injection site may occur.
Traditional chemotherapy (for example melphalan) is used less often as a first-line treatment than in the past, but still plays a role in preparation for stem cell transplantation and in certain combination treatments. Side effects are bone marrow failure, infections, nausea and long-term risks.
Immunomodulators
These medicines help the immune system to better recognize and attack myeloma cells. They are often part of combination treatments.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Immunomodulators (IMiDs) such as lenalidomide and pomalidomide are routinely used. They increase the chance that your immune cells will work against myeloma cells. Known side effects are anemia, increased risk of blood clots, fatigue and (rarely) nerve pain. They require regular monitoring of blood values.
Corticosteroids
ProveniIncluded in official guidelines, or approved by EMA or FDA
Corticosteroids (especially dexamethasone and prednisone) are used in almost every combination. They help myeloma cells die and at the same time suppress inflammatory reactions. They work quickly, which is important in acute phases. Long-term use carries risks: bone loss, increased susceptibility to infections, diabetes-like symptoms and mood swings.
Stem cell transplantation (SCT)
ProveniIncluded in official guidelines, or approved by EMA or FDA
With stem cell transplantation, remission is first achieved with chemotherapy and other medicines, after which your own stem cells are collected. You then receive a high dose of melphalan, and your stem cells are reinfused to rebuild your bone marrow. This can have considerable side effects: severe nausea, diarrhea, mouth inflammation, infection risks and (rarely) lung or heart damage. After transplantation, recovery takes weeks to months. Stem cell transplantation is primarily used in younger patients and can prolong the disease-free interval.
Monoclonal antibodies
These proteins help your immune system recognize and eliminate specific points on myeloma cells.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Antibodies directed against CD38 (such as daratumumab) or BCMA are widely used. Side effects can include infections (due to suppression of certain antibody production), fatigue and infusion cytokine release syndrome – a reaction with fever and flu-like symptoms, especially at first infusions. For certain antibodies, preventive measures are taken to prevent this.
Bispecific T-cell engagers (BiTEs)
ProveniIncluded in official guidelines, or approved by EMA or FDA
Newer agents like teclistamab and linvoseltamab are bispecific antibodies that directly link your T-cells to myeloma cells. They have demonstrated achieving significant responses, even in very difficult-to-treat disease. An important side effect is cytokine release syndrome – a severe inflammatory reaction with fever, blood pressure drop and (rarely) multi-organ failure, especially with higher disease burden. This is closely monitored, sometimes with preventive infusions of tocilizumab to reduce the reaction. Infections, fatigue and brain injuries (ICANS, immune effector cell-associated neurotoxicity) are also possible side effects that are actively monitored.
Targeted therapies and molecular targeting
ResearchediPositive results in clinical studies, not yet standard treatment
Research focuses on blocking specific genetic abnormalities that drive myeloma cells. Examples include agents targeting certain signaling pathways within the cell. These are primarily applied in clinical trials and may become future standard treatments as more research data becomes available.
Support for side effects
ProveniIncluded in official guidelines, or approved by EMA or FDA
Treatment of side effects is an essential part. This includes among others:
- Antibiotics and antiviral agents to prevent infections
- Agents for anemia (for example erythropoiesis-stimulating agents)
- Medications for nausea and vomiting
- Measures to prevent blood clots (antithrombosis)
- Pain relief
- Support of kidney function (especially important because myeloma can damage the kidneys)
This supportive care is essential to allow optimal tumor treatment.
Intensity and phases
In the first phase (newly diagnosed myeloma) an intensive schedule is often chosen with a view to stem cell transplantation (especially in younger patients) or less intensive combinations (especially in elderly or with serious comorbidities). After that comes maintenance therapy to delay relapse.
Once the disease returns after treatment (relapse), other agents are often tried. If myeloma becomes resistant to multiple agents (refractory), bispecific antibodies, CAR-T-cell therapy or investigational treatments may be an option.
CAR-T-cell therapy
ResearchediPositive results in clinical studies, not yet standard treatment Proven in several countries
CAR-T-cell therapy is a relatively new approach in which your T-cells are genetically modified outside your body so they can recognize and destroy myeloma cells. They are put back so they continue to work in your body. Known side effects are cytokine release syndrome and neurotoxicity. This is a very specialized and intensive approach that is only applied in specialized centers and mainly for very difficult-to-cure disease.
---
_This information never replaces a doctor's judgment. Always discuss your situation with your own healthcare provider._