Complicanze trombotiche nel mieloma multiplo

Mauro BerrettiniS.C. Medicina Generale-DH Oncologico

Ospedale di Orvieto

Mediterranean School of Oncology

Orvieto 22 Novembre 2009

Hemostasis-related complications in plasma cell dyscrasias

thrombocytopenia endothelial damageacquired von Willebrand disease acquired APC resistanceheparin-like anticoagulants hypofibrinolisisclotting factor deficiencies increased F.VIII/vWFamyloidosis lupus anticoagualant

Bleeding Thrombosis

Incidence of deep vein thrombosis (DVT) in monoclonal gammopathy (MGUS) and multiple myeloma(MM)

• US VA hospital records (1980-1996)

Incidence R.R

1000 pt/years

• General (4.196.197) 0.9

• MGUS (2374) 3.1 3.3

• MM( 6192) 8.7 9.2

Kristinsson S.Y.et al, Blood 2008;112:3582-86

MGUS

MM

C

Kristinsson SY et al., Blood 2008,112:3582-86

High variability due:• Age• History venous thromboembolism(VTE)• Stage of the disease• Hypercoagulability• Immobilization• CVC• Comorbidities• Therapy: chemotherapies, immunomodulatory

drugs (thalidomide,lenalidomide)

Incidence of deep vein thrombosis (DVT) in monoclonal gammopathy (MGUS) and multiple myeloma(MM)

Eby C., British Journal of Haematology, 2009; 145, 151-163

Meta-analysis of the incidence of venous thromboembolic events with induction thalidomide

Hicks L.K. et al., , Cancer Treatment Rewies,2008; 34:442-452

Meta-analysis of the incidence of venous thromboembolic events with maintenance thalidomide

Hicks L.K. et al., , Cancer Treatment Rewies,2008; 34:442-452

Clinical studies of thromboprophylaxis in MM patients receiving thalidomide or lenalidomide

Falanga A, Marchetti M., J.Clin.Onc.2009;27:4848-57

Meta-analysis of the incidence of venous thromboembolic events with induction thalidomide

Hicks L.K. et al., , Cancer Treatment Rewies,2008; 34:442-452

Prevention of venous thromboembolism (VTE) in MM

“In the absence of clear data from randomized studies,…..

…..proposed strategies are the result of common sense……

……further investigation is needed to define the best VTE prophylaxis…..”

The International Myeloma Working GroupPalumboA. et al., Leukemia 2008;22:414-423

Prevention of VTE in MMWhich drug?

efficacy safety

• ASA yes/? yes/?

• Warfarin

Low fixed dose no yes

Therapeutic dose yes no/?

• Low m.w.heparin yes yes

Prevention of VTE in MM patientsreceiving thalidomide or lenalidomide?

When? Which Patient? At higher risk:• Induction therapy• High dose dexametasone, doxorubicine• Multiagent chemotherapy• + other risk factors: age, history of VTE, CVC, comorbidities, immobilization

The International Myeloma Working GroupPalumbo A. et al., Leukemia 2008;22:414-423