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12 Myeloma Treatment Options

Medically reviewed by Todd Gersten, M.D.
Written by Kelly Crumrin
Updated on August 5, 2024

There are now more therapies for multiple myeloma than ever before, with new treatments under development in clinical trials. Hematologist-oncologists (specialists in both blood diseases and blood cancers) recommend treatments they think will be most effective based on the type of myeloma a person has, the stage of their myeloma, which treatments they’ve tried, and how their myeloma has responded to previous treatments.

Hematologist-oncologists also consider the person’s age, overall health, and any other conditions they may have. Ultimately, the treatment a person chooses should be based on a collaborative decision between them and their health care team.

In most cases, multiple myeloma is not curable. The majority of people with the condition experience a relapse (return of cancer) at some point. However, the effectiveness of new medications and treatment regimens means that, for many, multiple myeloma can be managed as a chronic condition. Some myeloma medications are so new that long-term data is not yet available. Despite this, survival rates for people with multiple myeloma continue to improve due to these advancements.

Types of Treatments for Myeloma

In the early stages of myeloma and related conditions, such as monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), doctors typically recommend watchful waiting (observation) with periodic tests and examinations. This approach allows for close monitoring of the condition without starting treatment immediately.

If test results show myeloma is progressing or that a person starts to show symptoms, doctors may then recommend initiating treatment. In certain cases, when myeloma cells possess specific genetic characteristics that indicate a high risk of progression, doctors might advise those with SMM to begin treatment earlier than usual.

Most cases of myeloma are treated with a combination of therapies. Healthy lifestyle choices, such as maintaining a nutritious diet and engaging in regular exercise, can help those with myeloma feel their best and recover more effectively from treatment. The treatment options listed below are the most common ones for myeloma.

1. Chemotherapy

Chemotherapy involves the use of drugs to destroy cancer cells by stopping or slowing their growth. High-dose chemotherapy followed by autologous stem cell transplant — which uses cells harvested from the person’s own body — is a common treatment for some people when they’re first diagnosed with symptomatic multiple myeloma.

Certain chemotherapy drugs must be infused intravenously (by IV), while others are injected intramuscularly (into a muscle) or taken orally. Chemotherapy is often given in three different phases: induction therapy (also called “initial therapy”), consolidation therapy, and maintenance therapy. Different drugs or doses may be used during each phase.

There are many classes of chemotherapy drugs for myeloma. Most chemotherapy drugs used for myeloma are given in combinations of two or more. Chemotherapy medications may also be combined with other classes of drugs, including corticosteroids — such as dexamethasone and prednisone — or immunomodulatory drugs (see below).

If your myeloma progresses, or if you experience significant side effects, your medical oncologist may adjust your dosage or change the combination of drugs you receive. Some chemotherapy drugs are approved by the U.S. Food and Drug Administration (FDA) to treat all cases of myeloma. Others are only approved to treat myeloma that is refractory (resistant to treatment) or relapsed (returned after being treated).

Common classes of chemotherapy drugs used for myeloma include:

  • Alkylating agents — These drugs prevent the growth of cancer cells by inhibiting and damaging their DNA. They include melphalan (Alkeran, Evolema), cyclophosphamide, carmustine (BiCNU), and bendamustine (Treanda).
  • Anthracyclines — These treatments slow the growth of cancer cells by interfering with cell division. They include doxorubicin (Adriamycin) and doxorubicin liposome (Doxil).

Chemotherapy Side Effects

Each class of chemotherapy drugs causes different side effects, some of which are very serious. What side effects you experience will depend on many factors, including the drug combination your doctor prescribes, your dosage, and how well your body can tolerate the treatment. You may be able to manage some side effects with additional medication.

The most common side effects of chemotherapy include:

  • Fatigue
  • Nausea
  • Vomiting
  • Diarrhea
  • Loss of appetite
  • Weight loss
  • Hair loss
  • Skin problems
  • Mouth sores

Some chemotherapy treatments also affect reproduction and fertility in many ways, both temporarily and permanently. Other serious late-term side effects of chemotherapy for myeloma can include damage to the heart and lungs, early menopause, and a higher risk for developing other cancers.

2. Immunomodulatory Drugs

Other medications used to treat myeloma include immunomodulatory drugs. These medications alter the way your immune system functions, enhancing its ability to fight cancer more effectively. Immunomodulators approved for use are thalidomide (Thalomid), lenalidomide (Revlimid), and pomalidomide (Pomalyst).

Lenalidomide is currently the standard of care used in maintenance for myeloma and is also used in combination with other drugs for as induction treatment. Studies have shown that lenalidomide can significantly improve progression-free survival (the time until a treated disease gets worse). Maintenance therapy begins after induction therapy (the initial treatment) and consolidation therapy (the next treatment) of high-dose chemotherapy with stem cell transplant.

In a study, maintenance therapy with lenalidomide sustained remission for at least 57 months in 50 percent of participants after a stem cell transplant, compared to 30 months without maintenance treatment. Lenalidomide is considered a well-tolerated drug, which is one reason it has become a standard of care for maintenance therapy. Side effects include an increased risk of changes in blood counts and a higher risk of blood clots.

Other immunomodulatory medications such as thalidomide, which has been used in maintenance therapy for myeloma, are now considered less advantageous because of toxicity and the risk of peripheral neuropathy (damage to nerves outside the brain and spinal cord).

3. Monoclonal Antibodies

Monoclonal antibodies are genetically engineered proteins that can kill cancer cells directly or aid the immune system in targeting and destroying cancer cells. Monoclonal antibodies approved to treat myeloma include:

Daratumumab is sometimes used for maintenance therapy in combination with lenalidomide.

4. CAR T-Cell Therapy

Chimeric antigen receptor T-cell therapy (CAR T-cell therapy) modifies your T cells to enhance their ability to fight cancer.

During CAR T-cell therapy, oncology doctors remove a person’s T cells (a type of white blood cell). The T cells are genetically modified in a lab to “train” them to recognize a protein called B-cell maturation antigen (BCMA) found on the surface of myeloma cells. Once modified, the T cells are returned to the person with myeloma, where they begin attacking cancerous plasma cells.

Approved CAR T-cell treatments for myeloma include idecabtagene vicleucel (Abecma) and ciltacabtagene autoleucel (Carvykti). Both of these medications are available only after other treatments have failed or stopped working.

5. Bispecific T-Cell Engagers

Bispecific T-cell engagers (BiTEs) are a newer approach to treating relapsed or refractory multiple myeloma that involves antibodies that can bind to two antigens at once. The FDA approved the BiTE teclistamab-cqyv (Tecvayli) in 2022 for treating people who had previously tried three prior lines of therapy.

BiTEs work by targeting BCMA and the CD3 protein found in T cells. As a result, teclistamab-cqyv causes tumor-cell lysis (destruction).

Other bispecific T-cell engagers sometimes used to treat myeloma are talquetamab-tgvs (Talvey) and elranatamab-bcmm (Elrexfio).

6. Targeted Therapies

Targeted therapies limit how much cancer cells can divide, multiply, and spread. There are a number of these kinds of therapies for myeloma.

Proteasome inhibitors, such as carfilzomib (Kyprolis), ixazomib (Ninlaro), and bortezomib (Velcade), stop myeloma cells from destroying extra proteins. When too many proteins build up and the cell can’t remove them, the cell dies.

Mayo Clinic recommendations include using bortezomib for maintenance therapy in people with certain high-risk genetic abnormalities. Side effects for bortezomib include lowered blood counts, diarrhea, and fatigue. These drugs may also be recommended after relapses or if earlier treatments don’t work.

Another targeted therapy, selinexor (Xpovio), is in a new class of medications called “nuclear export inhibitors” that prevent cancer cells from properly transporting proteins.

7. Bisphosphonates

Bisphosphonates, such as pamidronate (Aredia) and zoledronic acid (Zometa), can reduce the risk of complications related to bone lesions in some people with myeloma. Denosumab (Xgeva), a biologic drug, is often used to treat myeloma instead of bisphosphonates, particularly in those with reduced kidney function. It helps lower the risk of spinal fractures and spinal cord compression in people whose spines have been weakened by myeloma.

8. Radiation

Radiation therapy (also called radiotherapy) is commonly used to treat solitary plasmacytoma — a single lesion in the bone or soft tissues. Radiation therapy may also be used to treat multiple myeloma in cases where chemotherapy has been ineffective at reducing pain in a limited number of bone lesions.

Radiation interferes with cell division. Since cancer cells divide much more rapidly than normal cells, they’re more vulnerable to radiation. Radiation kills cancer cells, while the normal, healthy cells of your body are better able to survive and heal.

Radiation schedules differ based on factors including the size, location, and type of tumor and what other treatments a person is receiving.

Radiation Therapy Side Effects

Most common side effects of external beam radiation to the bone are short term. These include:

  • Fatigue
  • Swelling
  • Nausea
  • Diarrhea
  • Skin damage similar to sunburn

These changes are usually gone within six to 12 months after radiation treatment ceases, but they may linger for as long as two years.

Less common side effects include nerve damage that can leave parts of the body feeling painful, weak, or numb. A very rare but serious side effect of external beam radiation can include developing a different type of cancer called angiosarcoma.

9. Surgery

In some cases of solitary plasmacytoma, extramedullary myeloma (plasma cell tumors located outside of the bones), or localized myeloma, your doctor may recommend surgical resection — cutting away the lesion or removing the tumor from the healthy bone or tissue.

In those whose myeloma has affected the pelvis or the spine, hip replacement or spinal surgery may relieve pain and restore the ability to walk.

10. Stem Cell Transplants

Stem cell transplants, following high-dose chemotherapy, are a common treatment for people newly diagnosed with symptomatic multiple myeloma. The purpose of a stem cell transplant is to replace cancerous bone marrow cells with stem cells that will generate healthy bone marrow. Stem cell transplants occur after the cancerous cells of the bone marrow have been destroyed with chemotherapy.

In the past, cells for transplants were sourced from bone marrow, leading some people to still refer to stem cell transplants as “bone marrow transplants.” However, blood is now the most common source of stem cells for transplant in multiple myeloma cases.

Autologous vs. Allogeneic Stem Cell Transplants

There are two types of stem cell transplant: autologous and allogeneic. The majority of people with multiple myeloma receive an autologous stem cell transplant.

In an autologous stem cell transplant, stem cells are harvested from the person’s own body. Autologous transplants are preferable in most cases because the cells do not attack the body. However, the risk is that the harvested stem cells may be contaminated with myeloma cells, potentially contributing to a relapse. Autologous stem cell transplantation cannot cure myeloma.

Less commonly, an allogeneic stem cell transplant may be considered. In an allogeneic transplant, stem cells are harvested from a donor. Allogeneic transplants can cure myeloma in some cases, but they carry a high risk of severe side effects and death.

Ideally, allogeneic stem cell transplants will trigger a process known as “graft-versus-tumor” or “graft-versus-myeloma effect,” in which the transplanted cells help attack the cancer cells and potentially cure myeloma. However, the greater risk of graft-versus-host disease (GVHD) often outweighs this potential benefit of allogeneic stem cell transplant. In GVHD, the transplanted donor cells attack the host’s tissues. The effects of GVHD can range from mild, chronic symptoms to life-threatening emergencies.

How Do Stem Cell Transplants Work?

Receiving a stem cell transplant is similar to undergoing a blood transfusion. Between 30 percent and 40 percent of people with myeloma undergo outpatient stem cell transplants, with daily monitoring for side effects. Most individuals, however, will be admitted to the hospital and can expect a two- to three-week stay during recovery.

You’ll need a variety of medications after a stem cell transplant, including antibiotics, antivirals, and antifungals. You may also get transfusions and take erythropoietin (EPO), a hormone that encourages and speeds the growth of red blood cells.

Side Effects of Stem Cell Transplants

Short-term side effects of stem cell transplant can include:

  • Fatigue
  • Headaches
  • Fever and chills
  • Nausea
  • Vomiting
  • Diarrhea
  • Loss of appetite
  • Weight loss
  • Trouble sleeping
  • Skin rashes

After undergoing an autologous stem cell transplant, a person will receive several years of maintenance medications to sustain the treatment response. People who receive allogeneic stem cell transplants may need to take antirejection medication for life.

11. Supportive Treatments

Some treatments aren’t prescribed to fight myeloma but to reduce symptoms of the condition and the side effects of treatments. Supportive care can include medications and medical procedures. The goal of supportive treatments is to improve functionality and quality of life and to reduce the severity of side effects.

The most common supportive treatment plans for myeloma include:

  • Pain medications, including opioids like oxycodone (such as OxyContin) or hydromorphone (Dilaudid)
  • Anticonvulsants
  • Antidepressants
  • Medical marijuana
  • Regular flu and pneumonia vaccines
  • Blood transfusions
  • Intravenous immunoglobulin (IVIG)
  • Plasmapheresis (removal of harmful substances from the blood)
  • Kidney dialysis

12. Clinical Trials

For those who have had multiple relapses and exhausted their cancer treatment options, clinical trials may be a viable option. These studies test potential new treatments that aren’t yet FDA-approved for treating multiple myeloma but show promise. Clinical trials may also use new combinations of already-approved drugs that haven’t yet been tested together.

Numerous other drugs are in clinical trials for myeloma maintenance therapy. You can ask your health care providers if any of these studies to investigate potential treatments may be appropriate for you. As of July 2024, at least two drugs, iberdomide and megzidomide, are in clinical trials.

There are also promising trials underway for:

  • New combinations of drugs
  • New bispecific monoclonal antibodies
  • New CAR T-cell therapies
  • Other bispecific monoclonal antibodies

If you’re interested in learning more about clinical trials for relapsing multiple myeloma, talk to your hematologist-oncologist. They can recommend studies for which you may be eligible and discuss the benefits and risks of clinical trials.

Are There Natural Treatments for Myeloma?

No natural, alternative treatments have proved effective in clinical studies to treat myeloma. However, many people have found various complementary or alternative therapies effective for managing myeloma symptoms and side effects of myeloma treatment, such as pain, fatigue, nausea, anxiety, and depression.

Some people have reported feeling better after therapies such as acupuncture, acupressure, or aromatherapy. Dietary supplements — including L-glutamine, the Japanese herb goshajinkigan, and omega-3 fatty acids — may also have a beneficial effect.

However, since some natural or complementary treatments can interfere with myeloma medications or cause their own side effects, it’s important to talk to your health care team before trying any.

Financial Assistance for Myeloma Treatments

Treatment of multiple myeloma can be very expensive. Some manufacturers of antimyeloma medications offer copay assistance programs for people with health insurance who have trouble affording their copay. Some people with low income and no health insurance qualify for programs that provide free medication.

Several nonprofit foundations offer guides to help find assistance paying for myeloma medications. Visit the links below for more information:

Talk With Others Who Understand

MyMyelomaTeam is the social network for people with myeloma. On MyMyelomaTeam, more than 25,000 members come together to ask questions, give advice, and share their stories with others who understand life with myeloma.

What treatments have you tried for myeloma? What were your experiences? Share in the comments below, or start a conversation by posting on your Activities page.

References
  1. Treatments for Multiple Myeloma — Multiple Myeloma Research Foundation
  2. About Multiple Myeloma — UCSF Helen Diller Family Comprehensive Cancer Center
  3. Watchful Waiting for Multiple Myeloma — Canadian Cancer Society
  4. When To Initiate Treatment in Smoldering Multiple Myeloma — Clinical Advances in Hematology & Oncology
  5. Myeloma First Line Treatment — Blood Cancer UK
  6. Drug Therapy for Multiple Myeloma — American Cancer Society
  7. Treatment Options for Multiple Myeloma and Other Plasma Cell Disorders — American Cancer Society
  8. Multiple Myeloma Treatment & Pharmacologic Management — Cancer Therapy Advisor
  9. Chemotherapy and Drug Therapy: Myeloma — Leukemia & Lymphoma Society
  10. Multiple Myeloma Medications — International Myeloma Foundation
  11. Chemotherapy — Macmillan Cancer Support
  12. How Cancer and Cancer Treatment Can Affect Fertility in Males — American Cancer Society
  13. How Cancer and Cancer Treatment Can Affect Fertility in Females — American Cancer Society
  14. Immunomodulators — Cleveland Clinic
  15. Abecma Home Page — Bristol Myers Squibb
  16. Carvykti Homepage — Janssen Biotech
  17. Chimeric Antigen Receptor (CAR) T-Cell Therapy — Leukemia & Lymphoma Society
  18. Maintenance Strategies Post-Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma — Clinical Hematology International
  19. Prolonged Lenalidomide Maintenance Therapy Improves the Depth of Response in Multiple Myeloma — Blood Advances
  20. CAR T-Cell Therapy and Its Side Effects — American Cancer Society
  21. FDA Approves Novel CAR T-Immunotherapy for the Treatment of Multiple Myeloma — Leukemia & Lymphoma Society
  22. FDA Approves Teclistamab-Cqyv for Relapsed or Refractory Multiple Myeloma — U.S. Food and Drug Administration
  23. Teclistamab-Cqyv: The First Bispecific T-Cell Engager Antibody for the Treatment of Patients With Relapsed or Refractory Multiple Myeloma — Journal of the Advanced Practitioner in Oncology
  24. Targeted Therapy To Treat Cancer — National Cancer Institute
  25. Therapy for Relapsed Multiple Myeloma: Guidelines From the Mayo Stratification for Myeloma and Risk-Adapted Therapy — Mayo Clinic Proceedings
  26. Role of Histone Deacetylase Inhibitors in the Treatment of Lymphomas and Multiple Myeloma — Hematology/Oncology Clinics of North America
  27. Supportive Care and Disease Complications: Myeloma — Leukemia & Lymphoma Society
  28. Radiation Therapy for Multiple Myeloma — American Cancer Society
  29. Radiation Therapy — Leukemia & Lymphoma Society
  30. Surgery for Multiple Myeloma — American Cancer Society
  31. Stem Cell Transplant for Multiple Myeloma — American Cancer Society
  32. Graft-Versus-Host Disease — Leukemia & Lymphoma Society
  33. Stem Cell or Bone Marrow Transplant Side Effects — American Cancer Society
  34. Experience of Severe Fatigue in Long-Term Survivors of Stem Cell Transplantation — Bone Marrow Transplantation
  35. Supportive Care — City of Hope
  36. Treatments for Late (or Subsequent) Relapse — International Myeloma Foundation
  37. Multiple Myeloma Bone Pain — Memorial Sloan Kettering Cancer Center
  38. Pain Management in Patients With Multiple Myeloma: An Update — Cancers
  39. Marijuana and Cancer — American Cancer Society
  40. Flu Shots and Immunizations — Leukemia & Lymphoma Society
  41. Supportive Treatments for Patients With Multiple Myeloma — American Cancer Society
  42. Treatment of Multiple Myeloma With Renal Involvement: The Nephrologist’s View — Clinical Kidney Journal
  43. Natural Products and Complementary Therapies for Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review — Critical Reviews in Oncology/Hematology
  44. Financial and Transportation Support — Multiple Myeloma Research Foundation
  45. Financial and Insurance Matters — American Cancer Society
  46. Online Resources — International Myeloma Foundation

Updated on August 5, 2024

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Todd Gersten, M.D. is a hematologist-oncologist at the Florida Cancer Specialists & Research Institute in Wellington, Florida. Review provided by VeriMed Healthcare Network. Learn more about him here.
Kelly Crumrin is a senior editor at MyHealthTeam and leads the creation of content that educates and empowers people with chronic illnesses. Learn more about her here.

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