Anemia in Multiple Myeloma and Its Management

Abstract

Anemia is a common feature of multiple myeloma. Its causation is multifactorial, but some patients benefit from recombinant human erythropoietin (rHuEpo). Etiology of Anemia in Multiple Myeloma Anemia is a frequent finding in patients with myeloma, second only to skeletal lytic lesions. Approximately 70% of patients have anemia at diagnosis a median hemoglobin of approximately 10.5 g/dL. The severity of anemia is important in determining the stage and prognosis of disease as determined by the Durie and Salmon staging criteria. 1 Like anemia of chronic disease, the anemia of myeloma is generally normochromic and normocytic, and it is characterized by shortened erythrocyte survival with failure of the bone marrow to compensate by increased red cell production. This depressed red cell production is multifactorial and includes the following factors: (1) impaired availability of storage iron, (2) inadequate erythropoietin response to the level of anemia, and (3) overproduction of cytokines that are capable of inhibiting erythropoiesis. 2 In addition to direct inhibitory effects on erythroid precursors, these cytokines (including tumor necrosis factor, interleukin-1, and interleukin-6) may decrease reutilization of iron stores from reticuloendothelial cells and may interfere with erythropoietin production by the kidney. 2 Although many mechanisms contribute to the development of anemia in patients with multiple myeloma, the main mechanism is related to defective red cell production by the bone marrow. Reasons for defective erythropoiesis include marrow replacement with myeloma cells and cumulative marrow suppression from chemotherapy. However, the main mechanism of reduced erythropoiesis is related to defective production of erythropoietin or impaired erythroid marrow response to erythropoietin. 3 Beguin et al 4 reported that serum erythropoietin levels were low in approximately 25% of all patients with myeloma. This number increased to 50% of patients with stage III disease and 60% of those with renal impairment. In addition to being the primary growth factor for erythroid precursors, erythropoietin is also a survival factor and prevents apoptosis or programmed cell death of proerythroblasts. 5 Therefore, reduced levels of erythropoietin results in both reduced red cell production and shortened red cell survival. Based on these findings, the use of recombinant human erythropoietin (rHuEpo) may be helpful in the treatment of anemia associated with myeloma.

Improvement in quality of life for cancer patients treated with epoetin alfa

“…Of those with the haematological malignancies, leukaemia and lymphoma, 78% and 25% were transfused with red cells because of anaemia respectively. Anaemia is present at diagnosis in almost 70% of patients with multiple myeloma and can be severe (Dalton 1998). However, in a large‐scale audit that included patients with cancer of the lung, ovaries or breast ( n = 2506), the incidence of anaemia assessed indirectly by the requirement for blood transfusion was 43%, 41% and 19%, respectively, and the proportion of these patients requiring more than one transfusion was 22%, 21% and 7% respectively (Barrett‐Lee et al 2000).…”