Multiple Myeloma — GCC Nursing Guide

ℹDefinition: Multiple myeloma is a malignant plasma cell dyscrasia characterised by clonal proliferation of plasma cells in the bone marrow, monoclonal protein production, and end-organ damage.

CRAB Criteria (End-Organ Damage)

C — Calcium >2.75 mmol/L (>11 mg/dL) or >0.25 mmol/L above upper limit of normal
R — Renal impairment: creatinine >177 µmol/L (>2 mg/dL) or CrCl <40 mL/min attributable to myeloma
A — Anaemia: Hb <100 g/L or >20 g/L below lower limit of normal
B — Bone lesions: ≥1 lytic lesion on skeletal survey, CT, or PET-CT

SLiM-CRAB: Additional MDE Criteria

S — Sixty percent (≥60%) clonal plasma cells in marrow
Li — Light chain ratio ≥100 (involved:uninvolved sFLC)
M — MRI: >1 focal lesion ≥5 mm

Any 1 SLiM or CRAB criterion = Myeloma Defining Event → treatment required regardless of symptoms.

Disease Spectrum

Entity	M-protein	Bone Marrow PCs	End-Organ Damage	Action
MGUS	<30 g/L IgG/IgA or <500 mg/24h BJP	<10%	Absent	Observe; annual review
Smouldering Myeloma	≥30 g/L or BJP ≥500 mg/24h	10–59%	Absent (no SLiM)	Observe; 3–6 monthly; trial enrolment
Active Myeloma	Any	≥10% (any)	CRAB/SLiM present	Treat immediately

Diagnostic Workup

Laboratory

Serum Protein Electrophoresis (SPEP) — M-spike quantification
Serum Free Light Chains (SFLC) — kappa/lambda ratio
Immunofixation (IFE) — isotype characterisation
24-hour urine BJP (Bence Jones Protein)
FBC, creatinine, calcium, albumin, LDH, β2-microglobulin

Bone Marrow & Imaging

Bone marrow biopsy: ≥10% clonal plasma cells confirms diagnosis
FISH/cytogenetics on marrow (del17p, t(4;14), t(14;16))
Skeletal survey (X-ray) — lytic lesions, pathological fractures
Whole-body low-dose CT (preferred over plain X-ray)
Whole-body MRI — spinal/extramedullary disease
PET-CT — metabolically active disease, treatment response

ISS / R-ISS Staging

Stage	ISS Criteria	R-ISS Addition	Median OS
I	β2-MG <3.5 mg/L + albumin ≥35 g/L	No high-risk cytogenetics + normal LDH	~62 months
II	Neither I nor III	Not I or III	~42 months
III	β2-MG ≥5.5 mg/L	High-risk cytogenetics OR elevated LDH	~29 months

High-Risk Cytogenetics (FISH)

del(17p)

TP53 deletion — worst prognosis; aggressive disease; shorter PFS with standard therapy

t(4;14)

FGFR3/MMSET translocation; intermediate-high risk; bortezomib-sensitive

t(14;16)

MAF translocation; aggressive; may be lenalidomide-resistant

Standard-risk: t(11;14), hyperdiploidy. All patients should have cytogenetics at diagnosis to guide treatment intensity.

✓Standard of Care (Transplant-eligible): VRd (Bortezomib + Lenalidomide + Dexamethasone) × 4–6 cycles → ASCT → lenalidomide maintenance. Daratumumab-VRd (Dara-VRd) is now preferred in fit, newly diagnosed patients where available.

Induction Regimens Overview

Regimen	Drugs	Setting	Key Nursing Points
VRd	Bortezomib + Lenalidomide + Dexa	NDMM — transplant & non-transplant eligible	Neuropathy monitoring, DVT prophylaxis, glucose monitoring
Dara-VRd	Daratumumab + VRd	Fit NDMM — preferred in 2024+ guidelines	Infusion reactions (pre-medicate), all VRd precautions
VCd / CyBorD	Bortezomib + Cyclophosphamide + Dexa	Renal impairment; cost-sensitive settings	Haemorrhagic cystitis risk — hydration, mesna if high-dose
Rd	Lenalidomide + Dexa	Non-transplant eligible (elderly/frail)	DVT prophylaxis critical; fatigue management

Bortezomib (Velcade) — Nursing Guide

Administration

Subcutaneous (SC) preferred over IV — reduced peripheral neuropathy (PN) incidence
SC sites: abdomen, thigh; rotate sites each injection
Weekly schedule (once/week) preferred over twice-weekly — fewer PN events, equivalent efficacy
Reconstitute with 1.4 mL NS for SC (3.5 mg/1.4 mL = 2.5 mg/mL)

Peripheral Neuropathy Monitoring

Assess before each cycle: tingling, numbness, burning feet
Grade 1–2 painful PN → dose reduction (1.3→1.0→0.7 mg/m²)
Grade 3 PN → hold until resolution, consider discontinuation
Acupuncture, gabapentin/pregabalin may help symptom control

Other Toxicities

Thrombocytopenia: nadir day 11, recovery day 21 — monitor FBC
GI: nausea, constipation, diarrhoea — laxatives prophylactically
HSV reactivation — acyclovir/valaciclovir prophylaxis mandatory
Infusion-related reactions (IV route): pre-hydrate, monitor BP

Dexamethasone — Nursing Guide

Standard Doses

High-dose: 40 mg weekly (days 1,8,15,22)
Low-dose: 20 mg weekly — preferred in patients >75 years

Key Toxicities & Nursing Interventions

Hyperglycaemia — monitor BGL; sliding scale insulin may be needed; advise diabetic patients to increase monitoring
Insomnia — administer in morning; avoid evening doses; sleep hygiene education
Mood changes / psychosis — assess mood at each visit; family involvement; avoid abrupt discontinuation
GI irritation / PUD — take with food; PPI prophylaxis (omeprazole 20 mg daily)
Fluid retention / oedema — daily weights; restrict sodium; diuretics if required
Adrenal suppression — do not stop abruptly; taper if discontinuing
Infection risk — PCP prophylaxis (co-trimoxazole) if cumulative dose high

!Ramadan Consideration: Patients fasting may require dosing time adjustment. Coordinate with physician and dietitian. High-dose steroids on fasting days increase hypoglycaemia risk in diabetics.

Lenalidomide (Revlimid) — DVT Prophylaxis

Lenalidomide + dexamethasone significantly increases VTE risk (up to 26% without prophylaxis).

Prophylaxis Strategy

Low risk: Aspirin 100 mg daily (1 VTE risk factor or fewer)
High risk: LMWH (enoxaparin 40 mg SC daily) — ≥2 risk factors, history of DVT, immobility, obesity, cardiac disease
Warfarin (INR 2–3) — alternative if LMWH not available
Assess risk monthly; adjust prophylaxis accordingly

REMS / Monitoring

FBC weekly for first 8 weeks, then monthly — watch for neutropenia (dose reduce at <0.5 × 10⁹/L)
Renal dose adjustment: CrCl 30–60 → 10 mg/day; CrCl <30 → 7.5 mg/day
Teratogenic — women of childbearing potential: two forms of contraception, monthly pregnancy test

Thalidomide — Nursing Guide

⚠REMS Programme mandatory. Thalidomide is teratogenic (Category X). Strict REMS enrolment required for patient AND prescriber.

Key Toxicities

Peripheral neuropathy — cumulative, irreversible; assess weekly; dose-limit at Grade 2
Constipation — prophylactic laxatives mandatory; high-fibre diet; hydration
DVT/PE — same prophylaxis strategy as lenalidomide
Somnolence/dizziness — dose at bedtime; fall prevention; no driving
Bradycardia — monitor HR; caution with beta-blockers
Pregnancy test monthly; two contraceptive methods required

Daratumumab Infusion Reactions

Infusion-related reactions (IRR) occur in ~40% of patients, predominantly on first infusion. Pre-medication is mandatory.

Pre-medication Protocol (administer 1–3 hours before infusion)

Methylprednisolone 100 mg IV (or equivalent) — corticosteroid
Cetirizine 10 mg oral (or diphenhydramine 25–50 mg IV) — antihistamine
Paracetamol 650–1000 mg oral — antipyretic
Post-infusion: oral methylprednisolone 20 mg on day 1 and day 2 after infusion

Infusion Rate Management

Cycle 1: start at 50 mL/h, escalate every 60 min by 50 mL/h (max 200 mL/h)
Subsequent cycles: start at 100 mL/h, escalate to 200 mL/h if tolerated
Stop infusion for Grade ≥2 IRR; manage per anaphylaxis protocol; resume at 50% rate when resolved

Accordions: Key Protocols

Bortezomib Peripheral Neuropathy Grading & Dose Adjustment+

Grade	Description	Dose Adjustment	Nursing Action
1	Asymptomatic — decreased DTRs or paraesthesia	No change	Document; monitor at each visit; patient education
1 Painful	Paraesthesia with pain — no functional impairment	Reduce to 1.0 mg/m²	Pain assessment tools (VAS/NRS); neuropathic agents
2	Interferes with ADLs (non-limiting)	Reduce to 0.7 mg/m²	OT/PT referral; safety assessment; gabapentin/pregabalin
2 Painful	Moderate pain; limiting instrumental ADLs	Hold until ≤Grade 1; resume at 0.7 mg/m²	Urgent physician notification; fall risk — bed rails, non-slip socks
3	Severe — limits self-care ADLs	Discontinue bortezomib	Urgent neurology referral; document as SAE; supportive care
4	Life-threatening — respiratory PN	Discontinue permanently	Emergency response; ICU liaison

ℹSC administration reduces Grade ≥2 PN from ~16% (IV) to ~6%. Weekly schedule reduces PN vs twice-weekly. Early detection and dose modification prevent irreversible damage.

ℹASCT Eligibility: Age typically <70 years (physiological age considered), adequate organ function (creatinine <177 µmol/L, LVEF ≥45%, DLCO ≥50%), no severe comorbidity. Transplant consolidates response after induction.

Autologous SCT Nursing Timeline (Day -6 to Day +30)+

Days -14 to -5: Stem Cell Mobilisation
G-CSF (filgrastim 10 mcg/kg/day SC) ± plerixafor. Nurse: monitor WBC, bone pain (paracetamol), leukapheresis preparation. Target: ≥2×10⁶ CD34+ cells/kg (ideally ≥4×10⁶).

Days -2 to -1: High-Dose Conditioning
Melphalan 200 mg/m² IV (140 mg/m² if renal impairment or age >65). Nurse: IV hydration before/after, antiemetics (ondansetron + dexamethasone), cryotherapy (ice chips) during infusion to reduce oral mucositis — START 30 min before melphalan, continue for 6 hours.

Day 0: Stem Cell Infusion
Thaw cells at 37°C, infuse via central line within 15 min. DMSO cryoprotectant causes garlic odour, nausea, bradycardia — monitor vitals every 15 min during infusion. Pre-medicate: hydrocortisone 100 mg IV + chlorphenamine 10 mg IV.

Days +1 to +10: Aplasia Phase
Pancytopenia nadir. Strict neutropenic precautions: HEPA-filtered room, visitor restriction (no children <12, no ill visitors), cooked food only (no fresh fruit/salads in severe neutropenia). Daily FBC, daily weights, strict I&O. G-CSF from day +5 in most protocols to accelerate engraftment.

Days +10 to +14: Engraftment
Neutrophil engraftment: ANC ≥0.5×10⁹/L for 3 consecutive days (typically day +10–14). Platelet engraftment: plt ≥20×10⁹/L without transfusion (typically day +12–18). Fever during aplasia = neutropenic sepsis until proven otherwise — blood cultures ×2 + empirical broad-spectrum IV antibiotics within 1 hour.

Days +14 to +30: Recovery & Discharge
Discharge criteria: ANC >1.0, plt >50, afebrile, tolerating oral intake. Discharge education: hand hygiene, food safety, avoid crowds, wound care, when to call (fever ≥38°C, bleeding, SOB). Outpatient follow-up day +30 for response assessment (M-protein, bone marrow).

Mucositis Management

Mouth Care Protocol (Q4H during aplasia)

Soft toothbrush; brush after each meal and at bedtime
Normal saline 0.9% rinse (1 tsp salt in 1L water) every 4 hours
Sodium bicarbonate rinse — neutralises oral acid
Avoid alcohol-based mouthwashes (drying)
Nystatin oral suspension for fungal prophylaxis (or fluconazole)
Morphine PCA for Grade 3–4 mucositis pain
Nutritional support: NGT or TPN if oral intake <50% for >3 days
Cryotherapy (ice chips) during melphalan infusion reduces severity by 50%

Infectious Complications & Prophylaxis

Pathogen	Prophylaxis	Duration
HSV	Acyclovir 400 mg BD	Until engraftment / CD4 >200
Candida	Fluconazole 150 mg daily	Until engraftment
Aspergillus	Posaconazole 300 mg daily (high-risk)	Aplasia period
PCP	Co-trimoxazole 480 mg BD 3×/week	6 months post-ASCT
Bacterial	Fluoroquinolone (levofloxacin) — per protocol	Aplasia period
CMV	Monitor CMV PCR; pre-emptive ganciclovir if positive	3 months post-ASCT

Nutritional Support During ASCT

Assessment & Goals

Dietitian review pre-ASCT; weekly weights during admission
Target: maintain pre-ASCT weight ± 5%
High-protein diet: 1.5–2 g/kg/day protein
Caloric target: 30–35 kcal/kg/day

Escalation Pathway

Oral supplements (Ensure/Fresubin) — first line
NGT feeding — if oral intake <60% for ≥3 days or Grade 3+ mucositis
TPN — if NGT not tolerated or GI dysfunction; monitor glucose, electrolytes, triglycerides
Reintroduce oral feeds as mucositis resolves; avoid neutropenic diet restrictions once ANC >1.0

!Relapsed/Refractory Myeloma (RRMM): Defined as progression after ≥1 prior line. Median OS improving with novel agents. Combination therapy targets multiple pathways simultaneously. Clinical trial participation strongly encouraged.

Second-Line and Beyond — Key Regimens

Drug	Class	Common Regimen	Key Nursing Points
Carfilzomib	Proteasome inhibitor (irreversible)	KRd, KD	Cardiac monitoring (BP, LVF), hydration, no dose escalation in cardiac history
Pomalidomide	IMiD (3rd gen)	PomDex, PVd	DVT prophylaxis (LMWH), REMS, neutropenia monitoring
Daratumumab	Anti-CD38 mAb	DKD, DPd, DVd	IRR (pre-medicate); interferes with blood bank cross-match — notify blood bank before infusion
Isatuximab	Anti-CD38 mAb	IsaKD, IsaPd	Similar to daratumumab IRR; blood bank interference
Elotuzumab	Anti-SLAMF7 mAb	EloRd, EloPd	IRR; pre-medicate with dexamethasone, H1/H2 blockers, paracetamol
Selinexor	XPO1 inhibitor	Sd (weekly)	Nausea/vomiting (ondansetron prophylaxis), weight loss, fatigue, thrombocytopenia
Belantamab	Anti-BCMA ADC	Monotherapy	Corneal toxicity (keratopathy) — mandatory ophthalmology before each dose; blurred vision = HOLD

CAR-T Cell Therapy

Approved Agents

Idecabtagene vicleucel (ide-cel / Abecma) — anti-BCMA; for ≥4 prior lines
Ciltacabtagene autoleucel (cilta-cel / Carvykti) — anti-BCMA; for ≥4 prior lines

Process Overview

Leukapheresis → manufacturing (4–8 weeks) → lymphodepletion (fludarabine + cyclophosphamide) → CAR-T infusion

Cytokine Release Syndrome (CRS) — Nursing Monitoring

Onset: typically 1–14 days post-infusion; peak days 7–10
Grade 1: fever ≥38°C → paracetamol; monitor closely
Grade 2: fever + hypotension or hypoxia → tocilizumab 8 mg/kg IV ± fluids/O₂
Grade 3–4: ICU-level care; dexamethasone 10 mg QID; repeated tocilizumab (max 3 doses)
Monitor: temp q4h, BP, SpO₂, ferritin, CRP, LDH — escalating ferritin = macrophage activation syndrome

ICANS (Immune Effector Cell-Associated Neurotoxicity Syndrome)

Symptoms: confusion, tremor, dysphasia, seizures, cerebral oedema
ICE score assessment every shift (Orientation/Naming/Commands/Writing/Attention)
Grade ≥2: dexamethasone 10 mg IV q6h; neurology consult; seizure precautions
MRI brain + EEG for Grade ≥3 ICANS

!GCC Context: CAR-T is not widely available in GCC public hospitals (2026). Patients requiring CAR-T should be referred to accredited international centres (UK, USA, Germany). Early referral essential given long manufacturing timeline.

Bispecific Antibodies

Teclistamab (Tecvayli) — Anti-BCMA × CD3

Approved for RRMM after ≥4 prior lines including PI, IMiD, anti-CD38
Step-up dosing: 0.06 mg/kg SC (Day 1) → 0.3 mg/kg (Day 4) → 1.5 mg/kg weekly
Hospitalisation required for first 48h after each step-up dose for CRS monitoring
CRS occurs in ~72% (mostly Grade 1–2); ICANS ~15%
Neutropenia: G-CSF support; infection prophylaxis mandatory (IVIG supplementation for hypogammaglobulinaemia)
Educate patient: report fever, confusion, difficulty speaking immediately

Plasmapheresis for Hyperviscosity

Indications: hyperviscosity syndrome (serum viscosity >4 cP); IgM myeloma/Waldenstrom most common
Symptoms: visual changes, confusion, bleeding, headache, shortness of breath
Nurse: large-bore IV access or tunnelled CVC; anticoagulation per protocol; monitor BP/HR during procedure; replacement fluid (albumin 5% or FFP)
Bridging measure — treat underlying myeloma concurrently

Palliative Pathway Transition

Discuss goals of care when ≥4th line exhausted or ECOG ≥3
Palliative care referral: pain management, bone pain, fatigue, psychosocial support
DNACPR discussion with patient and family
Hospice criteria: prognosis <6 months, patient preference for comfort-focused care

Zoledronic Acid & Denosumab — Bone Protection Protocol & ONJ Prevention+

Zoledronic Acid (Zometa)

Dose: 4 mg IV over ≥15 min, monthly × 24 months, then 3-monthly
Renal dose adjustment: CrCl 50–60 → 3.5 mg; CrCl 40–49 → 3.3 mg; CrCl 30–39 → 3 mg; CrCl <30 → DO NOT USE
Hydration: 500 mL NS before infusion; encourage oral fluids ≥2L/day
Monitor: creatinine before each dose; electrolytes (calcium, magnesium, phosphate)
Flu-like reaction: common after first dose — paracetamol prophylaxis

Denosumab (Xgeva)

Dose: 120 mg SC every 4 weeks
Preferred over zoledronic acid in renal impairment (CrCl <30)
Monitor: calcium and vitamin D supplementation mandatory (calcium 500 mg + Vit D 400 IU BD)
Hypocalcaemia risk: monitor serum calcium at each visit; highest risk in renal impairment
Rebound effect on stopping — do not discontinue abruptly if active bone disease

Osteonecrosis of the Jaw (ONJ) — Prevention Protocol

⚠ONJ risk increases with duration of bisphosphonate/denosumab use. Dental review is mandatory BEFORE starting therapy.

Complete all invasive dental procedures (extractions, implants, periodontal surgery) before starting bisphosphonate/denosumab; allow 4–6 weeks healing time
While on therapy: routine dental hygiene only (cleaning, fillings); avoid extractions if possible
If extraction unavoidable: drug holiday — hold bisphosphonate for 2 months before and 3 months after procedure; consider holding denosumab for one cycle
Advise patient to use chlorhexidine mouthwash; soft toothbrush; no removable dentures if poor fit

ONJ Grading

Grade	Description	Nursing/Medical Action
1	Exposed/necrotic bone — asymptomatic, no infection	Chlorhexidine 0.12% rinse BD; conservative management; hold drug
2	Exposed bone with pain and/or infection	Oral antibiotics (amoxicillin/metronidazole); surgical debridement consider; hold drug; dental-oncology MDT
3	Exposed bone with pain, infection, pathological fracture, orocutaneous fistula, osteolysis to inferior border	Surgical resection; IV antibiotics; permanent drug discontinuation; maxillofacial surgery referral

MSCC — Malignant Spinal Cord Compression: Nursing Emergency Protocol+

⚠MSCC is a haematological/oncological emergency. Time to treatment is critical — delays >24h from onset of neurological deficit result in permanent disability. Treat as Code Red.

Recognition — Symptoms (BACK-DEF mnemonic)

Back pain — new, severe, worse lying down or with Valsalva (pathological)
Arm/leg weakness — bilateral limb weakness below lesion level
Coordination loss — ataxia, wide-based gait
Knife-like band pain — radicular/girdle pain around chest or abdomen
Dysfunction of bladder/bowel — urinary retention (most common early sign), incontinence, constipation
Exam finding — sensory level, hyperreflexia, upgoing plantars
Flag — any neurological symptom in known myeloma = MSCC until proven otherwise

Immediate Nursing Actions (within 30 minutes)

Notify senior nurse and oncologist/haematologist immediately. Do NOT wait.

Strict bed rest — log-roll only. Spinal precautions until MRI result. No unsupported mobilisation.

IV access × 2; bloods (FBC, U&E, CMP, group and save, coagulation); urine catheter if retention suspected.

Dexamethasone 16 mg IV STAT (load) → 4 mg QID. Gastric protection with omeprazole. Blood glucose monitoring.

Emergency MRI whole spine (within 24h — within 1h if severe/rapid neurological deficit). Arrange urgently.

Neurosurgical consult (decompression surgery may be required in fit patients). Radiation oncology referral for radiotherapy planning.

Ongoing: pressure area care, DVT prophylaxis, bowel care, pain management, psychosocial support, physiotherapy.

Hypercalcaemia Management

!Corrected Ca >3.5 mmol/L = severe; admit for IV management. Correct calcium for albumin: Corrected Ca = Measured Ca + 0.02 × (40 − albumin)

Stepwise Management

Step 1: IV Saline — 0.9% NaCl 200–500 mL/h; target urine output 100–150 mL/h; strict I&O; monitor for fluid overload
Step 2: Bisphosphonate — Zoledronic acid 4 mg IV over 15 min (effect onset 2–4 days) OR pamidronate 90 mg IV over 4h
Step 3: Corticosteroids — Hydrocortisone 200 mg IV q12h (myeloma-specific; reduces calcium via decreased intestinal absorption)
Step 4: Calcitonin — 4–8 IU/kg SC/IM q12h for rapid reduction (effect in hours); tachyphylaxis after 48h
Step 5: Haemodialysis — for life-threatening hypercalcaemia with renal failure

Nursing Monitoring

Serum calcium, phosphate, magnesium, creatinine q4–6h initially
ECG monitoring (short QT, arrhythmias)
Neurological status (confusion, drowsiness — calcium encephalopathy)
Avoid thiazide diuretics (worsen hypercalcaemia); loop diuretics (frusemide) only after adequate rehydration

Renal Impairment — Nursing Management

ℹRenal impairment occurs in 20–50% of myeloma patients. Causes: light chain cast nephropathy, hypercalcaemia, hyperuricaemia, dehydration, NSAID use.

General Measures

Hydration: 2.5–3 L/day oral or IV — target urine output ≥100 mL/h during high light chain burden
Strict fluid balance; daily weight; monitor creatinine/electrolytes
Avoid NSAIDs — nephrotoxic; use paracetamol ± opioid for pain
Avoid IV contrast (CT with contrast) — use MRI or plain CT; if unavoidable, pre-hydrate and use iso-osmolar contrast
Allopurinol/rasburicase for hyperuricaemia if tumour lysis risk
Nephrology referral if eGFR <30 or acute deterioration

Drug Considerations in Renal Impairment

Bortezomib: no dose adjustment needed — hepatically metabolised; preferred PI in renal impairment
Lenalidomide: dose reduce per CrCl (see Tab 2)
Cyclophosphamide: reduce dose if CrCl <25 mL/min
Melphalan (oral): reduce dose if creatinine elevated; IV melphalan (ASCT) use 140 mg/m² if creatinine clearance <40
Zoledronic acid: avoid if CrCl <30; use denosumab instead

Venous Thromboembolism (VTE)

Myeloma itself is hypercoagulable (paraprotein, cytokines)
IMiDs (lenalidomide, thalidomide) markedly increase VTE risk — see Tab 2 for prophylaxis
Clinical DVT/PE: LMWH therapeutic dose × 6 months minimum; DOAC (rivaroxaban/apixaban) acceptable alternative
Educate: leg exercises, hydration, compression stockings, early ambulation
Report: unilateral leg swelling, SOB, chest pain, pleuritic pain — immediate assessment

Anaemia & Transfusion Support

Anaemia in myeloma: multifactorial (marrow infiltration, renal EPO deficit, chemotherapy-related, iron deficiency)
Transfusion threshold: Hb <70–80 g/L (symptomatic), or Hb <90 g/L in elderly/cardiac patients
Use irradiated and leucodepleted blood products (immunosuppressed patients)
Daratumumab patients: blood bank must be notified — drug coats RBCs and interferes with cross-match; request daratumumab-treated reagent cells
EPO (darbepoetin/epoetin) — consider in chemotherapy-related anaemia if Hb <100 g/L; VTE risk increases with EPO + IMiDs — use with caution
Iron supplementation: IV iron preferred if iron-deficient and concurrent EPO therapy

★GCC Nursing Context: This section addresses GCC-specific clinical considerations and examination preparation for DHA, DOH, and SCFHS-registered nurses.

GCC Clinical Practice Context

Patient Population

Myeloma incidence increasing in GCC — median age at diagnosis ~60 years (slightly younger than Western populations)
Higher rates of t(4;14) and del(17p) in some GCC studies — reinforces importance of cytogenetics at diagnosis
Late presentation common — CRAB criteria often present at diagnosis; education campaigns needed
High prevalence of diabetes and CKD in GCC — impacts dexamethasone dosing and bisphosphonate choice

Drug Availability in GCC

VRd (bortezomib + lenalidomide + dexamethasone) — available in GCC public hospitals (DHA, SEHA, MOH Saudi, HMC Qatar)
Daratumumab increasingly available — formulary approval varies by centre; require MDT approval and insurance pre-authorisation in private sector
CAR-T cell therapy (ide-cel, cilta-cel) — not available in GCC as of 2026; refer to accredited centres internationally (UK NICE-approved centres, USA, Germany)
Bispecific antibodies (teclistamab) — limited availability; compassionate use or clinical trial basis
Carfilzomib — available in tertiary GCC centres (King Faisal Specialist Hospital, Sheikh Khalifa Medical City, Cleveland Clinic Abu Dhabi)

Bisphosphonate Dental Protocols in GCC

GCC hospitals have established ONJ prevention pathways — mandatory dental review form before bisphosphonate initiation
High utilisation of private dental clinics — patients may have dental work performed privately without informing oncology team; educate patients to disclose bisphosphonate use to any dental provider
Halal-certified IV preparations must be confirmed where required

Ramadan & Treatment Considerations

!Coordinate all Ramadan-related dosing modifications with the haematologist, pharmacist, and dietitian. Decisions are patient-specific and respect religious choice.

Dexamethasone During Ramadan

High-dose weekly dexamethasone (40 mg) — advise to take dose immediately after Iftar (breaking fast) to reduce GI side effects and insomnia during sleep hours
Steroid-induced hyperglycaemia: glucose monitoring before Suhoor (pre-dawn meal) and 2h after Iftar; sliding scale adjustment
Diabetic patients on dexamethasone: increased risk of hypoglycaemia during fasting hours, hyperglycaemia after Iftar — endocrinology co-management recommended

Bortezomib & Lenalidomide

SC bortezomib can be given at any time — oral hydration maintained between Suhoor and Iftar
Lenalidomide: advise taking with Iftar meal to reduce GI side effects; maintain oral fluid intake after sunset
DVT risk may increase with reduced daytime hydration — reinforce post-sunset fluid intake; ambulatory patients encouraged to walk in evenings

General Nursing Guidance

Never advise a patient not to fast — this is a medical and religious decision; provide safety information and monitoring plan for patients who choose to fast
Fatigue: adjust activity schedules to avoid peak daytime hours; rest after Tarawih prayers
Outpatient appointments: consider post-Iftar clinic slots for fasting patients where available

DHA / DOH / SCFHS Exam Preparation

High-Yield Exam Topics

1. CRAB Criteria (memorise exact thresholds)

Ca >2.75 mmol/L | Creatinine >177 µmol/L | Hb <100 g/L | ≥1 bone lytic lesion
Any 1 CRAB = treatment needed
MGUS = M-protein + <10% PC + NO CRAB → observe only

2. Bortezomib Peripheral Neuropathy

SC preferred over IV (reduces PN)
Grade 2 painful → dose reduce to 0.7 mg/m²
Grade 3 → HOLD bortezomib
HSV prophylaxis mandatory

3. Hypercalcaemia Management Steps

Step 1: IV saline (most important initial step)
Step 2: Bisphosphonate (zoledronic acid)
Step 3: Steroids (hydrocortisone)
Step 4: Calcitonin (fastest acting — hours)
Avoid thiazide diuretics (they worsen hypercalcaemia)

4. MSCC Nursing Emergency

Back pain + new neurology = MSCC until proven otherwise
Immediate: bed rest (log-roll), IV dexamethasone 16 mg STAT, urgent MRI spine
Do NOT mobilise patient without MRI clearance
First sign of MSCC = back pain; late sign = paralysis

Practice Questions

Q1. A myeloma patient on VRd reports burning feet and tingling that now interferes with daily activities. Bortezomib neuropathy grade is?

Answer: Grade 2. Interferes with ADLs (non-limiting self-care) → dose reduce to 0.7 mg/m²

Q2. A myeloma patient presents with back pain, urinary retention, and bilateral leg weakness. FIRST nursing action?

Answer: Strict bed rest (log-roll precautions) + immediate physician notification + IV dexamethasone 16 mg STAT. This is MSCC. Do not mobilise.

Q3. Patient on lenalidomide + dexamethasone. Which DVT prophylaxis is appropriate for a patient with 3 VTE risk factors?

Answer: LMWH (enoxaparin 40 mg SC daily). ≥2 risk factors = high risk → LMWH (not aspirin alone).

Q4. Which bisphosphonate is preferred in a myeloma patient with CrCl 20 mL/min?

Answer: Denosumab 120 mg SC. Zoledronic acid is contraindicated when CrCl <30 mL/min.

Q5. Which chemotherapy agent used in ASCT conditioning is associated with mucositis that can be reduced by cryotherapy?

Answer: Melphalan (high-dose, 200 mg/m²). Ice chips during melphalan infusion reduce oral mucositis severity by ~50%.

Interactive CRAB Criteria Checker

Enter patient values to assess for myeloma defining events and urgency of haematology referral.

Corrected Calcium (mmol/L) — Normal: 2.1–2.6

Serum Creatinine (µmol/L) — Normal: 44–97 (F) / 62–115 (M)

Haemoglobin (g/L) — Normal: 120–160 (F) / 135–175 (M)

Bone Lesion Count on Imaging (0 = none)

Results

⚠ This tool is for educational reference only. Clinical decision-making requires full patient assessment and physician review. Results do not replace clinical judgement.

Multiple Myeloma Nursing Guide GCC Edition