Download Richtlijn: Multiple myeloma (2.0)

Multiple myeloma
Landelijke richtlijn, Versie: 2.0
Laatst gewijzigd: 01-06-2012
Methodiek: Consensus based
Verantwoording: Dutch Dieticians
Oncology Group
Inhoudsopgave
General...........................................................................................................................................................1
The untreated patient....................................................................................................................................2
Nutritional status.................................................................................................................................2
Hypercalcaemia..................................................................................................................................2
Renal function disorders.....................................................................................................................3
Chemotherapy...............................................................................................................................................4
Nutritional status and requirements....................................................................................................4
Nutritional symptoms..........................................................................................................................4
Radiotherapy.................................................................................................................................................6
Stem cell transplant......................................................................................................................................7
Aftercare.........................................................................................................................................................8
Palliative care................................................................................................................................................9
Disclaimer....................................................................................................................................................10
i
General
The guideline for multiple myeloma (or Kahler's disease) by the Dutch Dieticians Oncology Group
(Landelijke Werkgroep Diëtisten Oncologie, LWDO) and the Dutch Dieticians Haematology and Stem Cell
Transplants Group (Landelijk Overleg Diëtisten Hematologie en Stamceltransplantatie, LODHS) discusses
tumour-specific nutritional treatment. For general nutritional problems and nutritional advice in oncology
see the guideline General nutritional and dietary treatment (2.0).
For medical information see:http://www.hematologienederland.nl/en/dutch-society-of-hematology.
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The untreated patient
This chapter is divided into the following parts:
• Nutritional status
• Hypercalcaemia
• Renal function disorders
Nutritional status
At time of diagnoses a patient can be well-nourished or moderately or severely malnourished. Symptoms
such as bone pain, fatigue, anorexia, nausea and infection can result in deterioration of the nutritional
status.
Intervention goal
• Maintaining, improving or preventing unnecessary deterioration of the nutritional status.
Treatment policy
• Assess the nutritional status, if possible the body composition and the need for nutritional care.
• Inquire after renal function.
• Take a nutritional history.
• Determine the required amounts of energy, protein, fluid and other nutrients.
• Inform the patient on the link between nutritional status, disease and treatment.
• Monitor the nutritional status and the intake of food and fluid.
• Assess whether the advised nutrition can be used and adjust the advice if necessary.
Nutritional advice
• In the case of a reasonable life expectancy: adequate diet or protein-energy enriched nutrition in
the case of weight loss.
• No increased protein intake in the case of potential renal function impairment.
• See Weight loss.
• Palliative nutritional support in the case of a very brief life expectancy.
Hypercalcaemia
Malignant plasma cells produce substances that break down bone, resulting in elevated serum calcium
levels. Renal function impairment can develop due to the increased renal excretion of calcium.
Hypercalcaemia can cause severe thirst, polyuria, nausea and vomiting, constipation and a reduced level
of consciousness. Treatment consists of bisphosphonates to reduce the high turnover of bone and 3-5
litres of physiological saline solution per 24 hours until calcium levels have normalized. Good urine
production is important. Restricting the use of calcium-rich products such as milk and cheese has no effect
on hypercalcaemia due to cancer.
Intervention goal
• To prevent unnecessary restrictions, especially related to calcium intake.
Treatment policy
• Inform the patient that dietary calcium intake does not influence serum calcium levels.
• Inquire after the patient's fluid intake and the colour and frequency of urine.
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Richtlijn: Multiple myeloma (2.0)
Nutritional advice
• No dietary calcium restrictions.
• Generous intake of fluid (at least 1,5 to 2 litres daily).
Renal function disorders
The proliferating plasma cells produce paraprotein, an immunoglobulin that can cause renal function
disorders. Good diuresis is very important to prevent renal function disorders.
Renal function impairment develops due to deposition of paraproteinin the glomerular filter. The effect of
treatment can be awaited, as rapid recovery of renal function is expected. Hypercalcaemia can also impair
renal function. These disorders can necessitate haemodialysis.
Intervention goals
• Maintaining a good diuresis.
• Limiting the amount of nutritional waste products that are excreted through the kidneys.
Treatment policy
• Take a nutritional history focused on the intake of energy, protein, sodium, potassium and fluid.
• Assess the serum levels of urea, sodium, potassium and creatinine.
• Determine the required amounts of energy, protein, fluid, sodium, potassium and other nutrients.
• Monitor renal function based on creatinine clearance.
• Inquire after the diuresis (this depends on the renal function disorder).
Nutritional advice
• Sufficient energy intake (due to the breakdown of protein).
• Generous fluid intake (at least 2 litres daily).
• In the case of a creatinine clearance of <30 ml/min, a protein-restricted diet depending on the
degree of renal failure, combined with a sodium, potassium and/or fluid restriction if necessary.
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Chemotherapy
The chemotherapy administered in elderly patients is usually mild with relatively few side effects. The
chemotherapy administered in younger patients with a more aggressive treatment policy has more side
effects.
Nutritional status and requirements
The patient can be well-nourished or moderately or severely malnourished.
Corticosteroids are often administered as part of a chemotherapy cycle. The poor appetite due to cytostatic
drugs is somewhat compensated for by the corticosteroids. Fluid requirements are increased as waste
products from cell death and cytostatic drugs need to be removed and renal function protected.
Intervention goals
• Maintaining, improving or preventing unnecessary deterioration of the nutritional status.
• Informing the patient on symptoms that can arise during chemotherapy.
• The removal of waste products due to cell death and cytostatic drugs and the protection of renal
function.
Treatment policy
• Assess nutritional status, if possible body composition and the need for nutritional care.
• Take a nutritional history.
• Determine the required amounts of energy, protein, fluid and other nutrients.
• Inform the patient on side effects of treatment.
• Inquire after the colour and frequency of urine.
• Monitor the nutritional status and intake of fluid and food (when corticosteroid use leads to the
accumulation of large amounts of fluid, this can conceal the actual body weight).
• Assess whether the advised nutrition can be used and adjust the advice if necessary.
Nutritional advice
• Adequate diet or protein-energy-enriched diet in the case of weight loss.
• At least 2 litres of drinking fluid daily
• No increased protein intake in the case of potential renal function impairment.
• See Weight loss.
Nutritional symptoms
Nausea and vomiting
Nausea, with or without vomiting is caused by hypercalcaemia and certain cytostatic drugs. Nausea and
vomiting can develop acutely following a cycle of chemotherapy (4-24 hours) or later: between two days
and several weeks following the treatment cycle. There is usually no link between vomiting and diet.
Anti-emetics are administered and adjusted if necessary. Intravenous fluids are administered if necessary.
Alterations in taste and smell
Chemotherapy and the disease itself can have a negative effect on taste and smell. The sense of taste can
be reduced and/or increased sensitivity to certain tastes and smells can develop. Aversions to specific
foods, a heightened awareness of taste and smell or an unpleasant taste (metallic, cardboard or sand
taste) regularly occur. The sense of taste does not match the taste memory. Patients are more sensitive to
smells and often dislike the smell of various foods and other items such as perfume and cleaning products.
Diabetes mellitus
Treatment with high doses of corticosteroids can (sometimes temporarily) result in the development of
diabetes and fluid accumulation. Nutritional advice has little effect. The diabetes is often corrected after the
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Richtlijn: Multiple myeloma (2.0)
cessation of corticosteroid use.
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Radiotherapy
Radiotherapy generally consists of a brief number of radiation cycles (five to six) on a limited area of the
body (for example one vertebra). This usually results in very limited nutritional side effects.
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Stem cell transplant
For information, focus points, dietary measures, nutritional advice and references see Stem cell transplants
in Acute leukaemia.
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Aftercare
When a patient is discharged following a cycle of intensive chemotherapy, his decreased appetite and
changes in taste have usually not resolved yet and dietary intake is often suboptimal. If the patient has lost
weight during his hospital stay, nutritional advice and support are needed at home. The patient frequently
only spends a short period of time at home before being readmitted for further treatment. This especially
necessitates focus on a good nutritional status. The longer patients remain at home between cycles of
treatment, the fewer nutritional symptoms remain as appetite and taste almost always recover completely.
Intervention goal
• Maintaining and if necessary improving nutritional status
Treatment policy and advice
• See Weight loss.
When the patient is discharged after his stem cell transplant, the nutritional intake has usually not
recovered completely.
Especially following MA allogeneic SCT, patients frequently still suffer from dry mouth, nausea, vomiting
and rapid satiety. These patients require nutritional support at home for some time. Furthermore, these
patients have increased energy requirements as a result of treatment and regularly still require tube feeding
at home to prevent further weight loss.
Intervention goal
• Maintaining and if necessary improving nutritional status
Treatment policy
• Take a nutritional history focused on nutritional symptoms.
• Monitor the course of body weight and if possible body composition.
• Assess dietary intake.
Nutritional advice
• Protein-energy enriched diet
• (Additional) tube feeding in the case of insufficient oral intake expected to last over seven days
and/or weight loss of 5-10%.
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Palliative care
If chemotherapy has had little effect on the leukaemia, another form of chemotherapy will be initiated
directly, after consulting the patient. If this form of treatment also yields insufficient results indicating
refractory disease, the therapeutic options are limited. The patient enters the palliative phase and is
discharged as soon as possible.
If disease recurrence occurs following a stem cell transplant, a new SCT can be an option, but it can also
result in the patient reaching the palliative phase.
For nutritional interventions see Palliative care.
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Disclaimer
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