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Efentakis P, Varela A, Lamprou S, Papanagnou ED, Chatzistefanou M, Christodoulou A, Davos CH, Gavriatopoulou M, Trougakos I, Dimopoulos MA, Terpos E, Andreadou I. Implications and hidden toxicity of cardiometabolic syndrome and early-stage heart failure in carfilzomib-induced cardiotoxicity. Br J Pharmacol 2024. [PMID: 38679957 DOI: 10.1111/bph.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/25/2023] [Accepted: 09/12/2023] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Cancer therapy-related cardiovascular adverse events (CAEs) in presence of comorbidities, are in the spotlight of the cardio-oncology guidelines. Carfilzomib (Cfz), indicated for relapsed/refractory multiple myeloma (MM), presents with serious CAEs. MM is often accompanied with co-existing comorbidities. However, Cfz use in MM patients with cardiometabolic syndrome (CMS) or in heart failure with reduced ejection fraction (HFrEF), is questionable. EXPERIMENTAL APPROACH ApoE-/- and C57BL6/J male mice received 14 weeks Western Diet (WD) (CMS models). C57BL6/J male mice underwent permanent LAD ligation for 14 days (early-stage HFrEF model). CMS- and HFrEF-burdened mice received Cfz for two consecutive or six alternate days. Daily metformin and atorvastatin administrations were performed additionally to Cfz, as prophylactic interventions. Mice underwent echocardiography, while proteasome activity, biochemical and molecular analyses were conducted. KEY RESULTS CMS did not exacerbate Cfz left ventricular (LV) dysfunction, whereas Cfz led to metabolic complications in both CMS models. Cfz induced autophagy and Ca2+ homeostasis dysregulation, whereas metformin and atorvastatin prevented Cfz-mediated LV dysfunction and molecular deficits in the CMS-burdened myocardium. Early-stage HFrEF led to depressed LV function and increased protein phosphatase 2A (PP2A) activity. Cfz further increased myocardial PP2A activity, inflammation and Ca2+-cycling dysregulation. Metformin co-administration exerted an anti-inflammatory potential on the myocardium without improving LV function. CONCLUSION AND IMPLICATIONS CMS and HFrEF seem to exacerbate Cfz-induced CAEs, by presenting metabolism-related hidden toxicity and PP2A-related cardiac inflammation, respectively. Metformin retains its prophylactic potential in the presence of CMS, while mitigating inflammation and Ca2+ signalling dysregulation in the HFrEF myocardium.
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Affiliation(s)
- Panagiotis Efentakis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Aimilia Varela
- Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Sofia Lamprou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Michail Chatzistefanou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Andriana Christodoulou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, Plasma Cell Dyscrasias Unit, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Trougakos
- Department of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Department of Clinical Therapeutics, Plasma Cell Dyscrasias Unit, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, Plasma Cell Dyscrasias Unit, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
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Singh R, Sperling D, Delicce A, Golec S, Singh S, Zatorski N, Bienstock S, Mitter SS, Lerakis S, Sahni GD. Changes in Global Longitudinal Strain as a Predictor of Cardiotoxicity After Exposure to Carfilzomib. Am J Cardiol 2024; 217:29-30. [PMID: 38432340 DOI: 10.1016/j.amjcard.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/04/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Ranbir Singh
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Dylan Sperling
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anthony Delicce
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sophia Golec
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Supreet Singh
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole Zatorski
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Solomon Bienstock
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sumeet Singh Mitter
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stamatios Lerakis
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gagan D Sahni
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Geraldes C, Roque A, Sarmento-Ribeiro AB, Neves M, Ionita A, Gerivaz R, Tomé A, Afonso S, Silveira MP, Sousa P, Bergantim R, João C. Practical management of disease-related manifestations and drug toxicities in patients with multiple myeloma. Front Oncol 2024; 14:1282300. [PMID: 38585008 PMCID: PMC10995327 DOI: 10.3389/fonc.2024.1282300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
Multiple myeloma (MM) is a very heterogeneous disease with multiple symptoms and clinical manifestations. MM affects mainly elderly patients and is difficult to manage in the presence of comorbidities, polypharmacy, frailty and adverse events of disease-targeted drugs. The rapid changes in MM treatment resulting from constant innovations in this area, together with the introduction of numerous new drugs with distinct mechanisms of action and toxicity profiles, have led to an increased complexity in the therapeutic decision-making and patient management processes. The prolonged exposure to novel agents, sometimes in combination with conventional therapies, makes this management even more challenging. A careful balance between treatment efficacy and its tolerability should be considered for every patient. During treatment, a close monitoring of comorbidities, disease-related manifestations and treatment side effects is recommended, as well as a proactive approach, with reinforcement of information and patient awareness for the early recognition of adverse events, allowing prompt therapeutic adjustments. In this review, we discuss various issues that must be considered in the treatment of MM patients, while giving practical guidance for monitoring, prevention and management of myeloma-related manifestations and treatment-related toxicities.
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Affiliation(s)
- Catarina Geraldes
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Adriana Roque
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Institute of Physiology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Bela Sarmento-Ribeiro
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Manuel Neves
- Hemato-Oncology Unit, Champalimaud Foundation, Lisboa, Portugal
| | - Alina Ionita
- Hematology Department, Portuguese Institute of Oncology Francisco Gentil, Lisboa, Portugal
| | - Rita Gerivaz
- Serviço de Hemato-oncologia, Hospital Garcia de Orta, Lisboa, Portugal
| | - Ana Tomé
- Serviço de Hemato-oncologia, Hospital Garcia de Orta, Lisboa, Portugal
| | - Sofia Afonso
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário Cova da Beira, Covilhã, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Maria Pedro Silveira
- Serviço de Imuno-Hemoterapia, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - Patrícia Sousa
- Serviço de Imuno-Hemoterapia, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - Rui Bergantim
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
- Instituto de Investigação e Inovaçáo em Saúde, Universidade do Porto, Porto, Portugal
- Institute of Pathology and Molecular Immunology, Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Cristina João
- Hemato-Oncology Unit, Champalimaud Foundation, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
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Lee DH, Kumar A, Mohammed T, Peres LC, Alsina M, Bachmeier C, Blue BJ, Brayer J, Chandrasekhar S, Grajales Cruz A, De Avila G, Elmariah H, Faramand R, Freeman C, Jain M, Khadka S, Khimani F, Liu H, Nishihori T, Oswald LB, Castaneda Puglianini OA, Shain KH, Smith E, Baz RC, Locke FL, Oliveira GH, Alomar M, Hansen DK. Cardiac events after standard of care idecabtagene vicleucel for relapsed and refractory multiple myeloma. Blood Adv 2023; 7:4247-4257. [PMID: 37307173 PMCID: PMC10424134 DOI: 10.1182/bloodadvances.2023009766] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
Idecabtagene vicleucel (ide-cel) is a type of B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor T-cell (CAR-T) approved for the treatment of relapsed and refractory multiple myeloma (RRMM). Currently, the incidence of cardiac events associated with ide-cel remains unclear. This was a retrospective single-center observational study of patients treated with ide-cel for RRMM. We included all consecutive patients who received standard-of-care ide-cel treatment at least 1-month follow-up. Baseline clinical risk factors, safety profile, and responses were examined based on the development of a cardiac event. A total of 78 patients were treated with ide-cel, and 11 patients (14.1%) developed cardiac events: heart failure (5.1%), atrial fibrillation (10.3%), nonsustained ventricular tachycardia (3.8%), and cardiovascular death (1.3%). Only 11 of the 78 patients had repeat echocardiogram. Baseline risk factors associated with the development of cardiac events included being female sex and having poor performance status, λ light-chain disease, and advanced Revised International Staging System stage. Baseline cardiac characteristics were not associated with cardiac events. During index hospitalization after CAR-T, higher-grade (≥grade 2) cytokine release syndrome (CRS) and immune cell-associated neurologic syndrome were associated with cardiac events. In multivariable analyses, the hazard ratio for the association of the presence of cardiac events with overall survival (OS) was 2.66 and progression-free survival (PFS) was 1.98. Ide-cel CAR-T for RRMM was associated with similar cardiac events as other types of CAR-T. Worse baseline performance status and higher-grade CRS and neurotoxicity were associated with cardiac events after BCMA-directed CAR-T-cell therapy. Our results suggest that the presence of cardiac events may confer worse PFS or OS; although because of the small sample size, the power to detect an association was limited.
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Affiliation(s)
- Dae Hyun Lee
- Division of Cardiovascular Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Abhishek Kumar
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Turab Mohammed
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Lauren C. Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Melissa Alsina
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Christina Bachmeier
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Brandon J. Blue
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jason Brayer
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Sanjay Chandrasekhar
- Division of Cardiovascular Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Gabe De Avila
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Ciara Freeman
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Michael Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Sushmita Khadka
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Hien Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Laura B. Oswald
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Kenneth H. Shain
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Eric Smith
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Rachid C. Baz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Frederick L. Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Guilherme H. Oliveira
- Division of Cardiovascular Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Mohammed Alomar
- Division of Cardiovascular Medicine, University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Doris K. Hansen
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
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Tantawy M, Yang G, Algubelli RR, DeAvila G, Rubinstein SM, Cornell RF, Fradley MG, Siegel EM, Hampton OA, Silva AS, Lenihan D, Shain KH, Baz RC, Gong Y. Whole-Exome sequencing analysis identified TMSB10/TRABD2A locus to be associated with carfilzomib-related cardiotoxicity among patients with multiple myeloma. Front Cardiovasc Med 2023; 10:1181806. [PMID: 37408649 PMCID: PMC10319068 DOI: 10.3389/fcvm.2023.1181806] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Background Proteasome inhibitor Carfilzomib (CFZ) is effective in treating patients with refractory or relapsed multiple myeloma (MM) but has been associated with cardiovascular adverse events (CVAE) such as hypertension, cardiomyopathy, and heart failure. This study aimed to investigate the contribution of germline genetic variants in protein-coding genes in CFZ-CVAE among MM patients using whole-exome sequencing (WES) analysis. Methods Exome-wide single-variant association analysis, gene-based analysis, and rare variant analyses were performed on 603,920 variants in 247 patients with MM who have been treated with CFZ and enrolled in the Oncology Research Information Exchange Network (ORIEN) at the Moffitt Cancer Center. Separate analyses were performed in European Americans and African Americans followed by a trans-ethnic meta-analysis. Results The most significant variant in the exome-wide single variant analysis was a missense variant rs7148 in the thymosin beta-10/TraB Domain Containing 2A (TMSB10/TRABD2A) locus. The effect allele of rs7148 was associated with a higher risk of CVAE [odds ratio (OR) = 9.3 with a 95% confidence interval of 3.9-22.3, p = 5.42*10-7]. MM patients with rs7148 AG or AA genotype had a higher risk of CVAE (50%) than those with GG genotype (10%). rs7148 is an expression quantitative trait locus (eQTL) for TRABD2A and TMSB10. The gene-based analysis also showed TRABD2A as the most significant gene associated with CFZ-CVAE (p = 1.06*10-6). Conclusions We identified a missense SNP rs7148 in the TMSB10/TRABD2A as associated with CFZ-CVAE in MM patients. More investigation is needed to understand the underlying mechanisms of these associations.
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Affiliation(s)
- Marwa Tantawy
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Guang Yang
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Raghunandan Reddy Algubelli
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Gabriel DeAvila
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Samuel M. Rubinstein
- Department of Medicine, Division of Hematology, University of North Carolina, Chapel Hill, NC, United States
| | - Robert F. Cornell
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael G. Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Erin M. Siegel
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Oliver A. Hampton
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute. Tampa, FL, United States
| | - Ariosto S. Silva
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Daniel Lenihan
- Cape Cardiology Group, Saint Francis Medical Center, Cape Girardeau, MO, United States
| | - Kenneth H. Shain
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Rachid C. Baz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, United States
- Cancer Control and Population Sciences, UF Health Cancer Center, University of Florida, Gainesville, FL, United States
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El-Cheikh J, Moukalled N, Malard F, Bazarbachi A, Mohty M. Cardiac toxicities in multiple myeloma: an updated and a deeper look into the effect of different medications and novel therapies. Blood Cancer J 2023; 13:83. [PMID: 37208317 DOI: 10.1038/s41408-023-00849-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 04/15/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023] Open
Abstract
With the continuous improvement in survival of cancer patients, including those with multiple myeloma, related to the novel treatment agents and therapeutic approaches, the probability for patients to develop cardiovascular disease has significantly increased, especially in elderly patients and those with additional risk factors. Multiple myeloma is indeed a disease of the elderly population and so these patients are, solely by age, at an increased risk of cardiovascular disease. Risk factors for these events can be patient-, disease- and/or therapy-related, and they have been shown to adversely impact survival. Cardiovascular events affect around 7.5% of patients with multiple myeloma and the risk for different toxicities has considerably varied across trials depending on patients' characteristics and treatment utilized. High grade cardiac toxicity has been reported with immunomodulatory drugs (odds ratio [OR] around 2), proteasome inhibitors (OR 1.67-2.68 depending on the specific agent, and generally higher with carfilzomib), as well as other agents. Cardiac arrhythmias have also been reported with various therapies and drug interaction plays a significant role in that setting. Comprehensive cardiac evaluation before, during and after various anti-myeloma therapy is recommended and the incorporation of surveillance strategies allows early detection and management resulting in improved outcomes of these patients. Multidisciplinary interaction including hematologists and cardio-oncologists is critical for optimal patient care.
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Affiliation(s)
- Jean El-Cheikh
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Florent Malard
- Department of Hematology, Saint Antoine Hospital, AP-HP, Paris, France
| | - Ali Bazarbachi
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Hematology, Saint Antoine Hospital, AP-HP, Paris, France.
- Sorbonne University, INSERM UMRs 938, Centre de Recherche Saint-Antoine (CRSA), Paris, France.
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Li S, Suehs BT, Fu A, Sangaré L, Kim C, Gastanaga VM, Liu J, Yan H, Xu Y, Mikhael J. Heart Failure Among Patients with Multiple Myeloma Treated with Carfilzomib-Based Versus Non-Carfilzomib-Based Regimens in the United States by Race. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023:S2152-2650(23)00137-4. [PMID: 37258396 DOI: 10.1016/j.clml.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/28/2023] [Accepted: 04/24/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Carfilzomib treatment for multiple myeloma (MM) can increase heart failure risk. Whether this risk differs by race is unknown. PATIENTS AND METHODS We sought to estimate the incidence rates (IRs) of heart failure hospitalization among mostly 65-years-and-older US patients with MM by race treated with carfilzomib- and non-carfilzomib-based regimens in the real-world using Centers for Medicare & Medicaid Services Medicare Fee-for-Service data, Optum Clinformatics Data Mart, and Humana Research Database. The risk of heart failure hospitalization associated with a carfilzomib-based regimen was evaluated using propensity score matching among Black and White patients receiving second or later lines of therapy. RESULTS Most patient-episodes (88%) were in persons 65 years or older for the 3 cohorts combined. The IR (95% CI) of heart failure hospitalization was higher for patient-episodes treated with a carfilzomib-based regimen than those with a non-carfilzomib-based regimen for both White (14.5 [12.2-17.0] vs. 10.7 [10.3-11.2] events per person-years) and Black patients (15.8 [10.1-23.5] vs. 12.1 [10.9-13.4] events per person-years) in the Medicare cohort. After propensity score matching, the hazard ratio (95% CI) of increased heart failure hospitalization comparing carfilzomib-based to non-carfilzomib-based regimens for White patients (1.6 [1.3-2.0]) was similar to that of Black patients (1.7 [1.0-2.9]) in the Medicare Database, and in the Humana Database (1.4 [0.8-2.6] and 1.2 [0.4-3.5], respectively). CONCLUSION Although the IR of heart failure among patients with MM treated with a carfilzomib-based regimen was slightly higher, no evidence suggested the relative risk was different between White and Black patients with MM.
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Affiliation(s)
- Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States.
| | | | - Alan Fu
- Amgen Inc, Center for Observational Research (CfOR), Thousand Oaks, CA, United States
| | - Laura Sangaré
- Amgen Inc, Center for Observational Research (CfOR), Thousand Oaks, CA, United States
| | - Chris Kim
- Amgen Inc, Center for Observational Research (CfOR), Thousand Oaks, CA, United States
| | - Victor M Gastanaga
- Amgen Inc, Center for Observational Research (CfOR), Thousand Oaks, CA, United States
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Yihua Xu
- Humana Healthcare Research, Louisville, KY, United States
| | - Joseph Mikhael
- Applied Cancer Research and Drug Discovery Division, Translational Genomics Research Institute (TGen), City of Hope Cancer Center, Phoenix, AZ, United States
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8
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Monteith BE, Sandhu I, Lee AS. Management of Multiple Myeloma: A Review for General Practitioners in Oncology. Curr Oncol 2023; 30:4382-4401. [PMID: 37232792 DOI: 10.3390/curroncol30050334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Multiple myeloma (MM) is a malignant clonal plasma cell disorder in the bone marrow and is the second-most common hematologic malignancy in adults. Although patients with MM have a moderate life expectancy, it remains a heterogeneous disease that often requires multiple lines of chemotherapy for durable control and long-term survival. This review outlines current management strategies for both transplant-eligible and transplant-ineligible patients as well as for relapsed and refractory disease. Advances in drug therapies have widened management options and improved survival. In this paper, we also discuss implications for special populations and survivorship care.
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Affiliation(s)
- Bethany E Monteith
- Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Irwindeep Sandhu
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton AB T6G 1Z2, Canada
| | - Ann S Lee
- Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada
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Georgiopoulos G, Makris N, Laina A, Theodorakakou F, Briasoulis A, Trougakos IP, Dimopoulos MA, Kastritis E, Stamatelopoulos K. Cardiovascular Toxicity of Proteasome Inhibitors: Underlying Mechanisms and Management Strategies: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:1-21. [PMID: 36875897 PMCID: PMC9982226 DOI: 10.1016/j.jaccao.2022.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 02/24/2023] Open
Abstract
Proteasome inhibitors (PIs) are the backbone of combination treatments for patients with multiple myeloma and AL amyloidosis, while also indicated in Waldenström's macroglobulinemia and other malignancies. PIs act on proteasome peptidases, causing proteome instability due to accumulating aggregated, unfolded, and/or damaged polypeptides; sustained proteome instability then induces cell cycle arrest and/or apoptosis. Carfilzomib, an intravenous irreversible PI, exhibits a more severe cardiovascular toxicity profile as compared with the orally administered ixazomib or intravenous reversible PI such as bortezomib. Cardiovascular toxicity includes heart failure, hypertension, arrhythmias, and acute coronary syndromes. Because PIs are critical components of the treatment of hematological malignancies and amyloidosis, managing their cardiovascular toxicity involves identifying patients at risk, diagnosing toxicity early at the preclinical level, and offering cardioprotection if needed. Future research is required to elucidate underlying mechanisms, improve risk stratification, define the optimal management strategy, and develop new PIs with safe cardiovascular profiles.
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Key Words
- ACE, angiotensin-converting enzyme
- ACS, acute coronary syndrome
- AE, adverse event
- AF, atrial fibrillation
- ARB, angiotensin receptor blocker
- ASCT, autologous stem cell transplantation
- BP, blood pressure
- CVAE, cardiovascular adverse event
- ESC, European Society of Cardiology
- FMD, flow-mediated dilatation
- GLS, global longitudinal strain
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- IHD, ischemic heart disease
- IMiD, immunomodulatory drug
- Kd, carfilzomib and dexamethasone
- LA, left atrial
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MM, multiple myeloma
- NO, nitric oxide
- NP, natriuretic peptide
- OS, overall survival
- PBMC, peripheral blood mononuclear cell
- PFS, progression-free survival
- PH, pulmonary hypertension
- PI, proteasome inhibitor
- PWV, pulse wave velocity
- PrA, proteasome activity
- RRMM, relapse or refractory multiple myeloma
- SBP, systolic blood pressure
- TMA, thrombotic microangiopathy
- UPP, ubiquitin proteasome pathway
- VTE, venous thromboembolism
- Vd, bortezomib and dexamethasone
- WM, Waldenström’s macroglobulinemia
- bortezomib
- cardiovascular toxicity
- carfilzomib
- eNOS, endothelial nitric oxide synthase
- ixazomib
- proteasome inhibition
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Affiliation(s)
- Georgios Georgiopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Nikolaos Makris
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ageliki Laina
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Briasoulis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis P Trougakos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Greece
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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10
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Muacevic A, Adler JR, Miranda CJ, Gravina M. Carfilzomib-Induced Tumor Lysis Syndrome and Biventricular Heart Failure in a Patient With Multiple Myeloma. Cureus 2023; 15:e33538. [PMID: 36779143 PMCID: PMC9907735 DOI: 10.7759/cureus.33538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Carfilzomib is a proteasome inhibitor (PI) used in multiple myeloma (MM) that is resistant to other therapies. Despite its efficacy and potency, carfilzomib has been associated with kidney injuries, cardiovascular toxic effects, and hematological adverse events. Tumor lysis syndrome (TLS) following the use of PIs in MM, a malignancy not known to cause TLS, has seldom been reported. We present a case of a patient with a known diagnosis of MM who received prior therapy including bortezomib, a first-generation PI, developing worsening heart failure and new onset TLS days after the administration of carfilzomib.
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11
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Yuan S, Zhou JY, Yang BZ, Xie ZL, Zhu TJ, Hu HX, Li R. Prediction of cardiovascular adverse events in newly diagnosed multiple myeloma: Development and validation of a risk score prognostic model. Front Oncol 2023; 13:1043869. [PMID: 37025590 PMCID: PMC10070977 DOI: 10.3389/fonc.2023.1043869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Background Multiple myeloma (MM) is the second most common hematological malignancy, and the treatments markedly elevate the survival rate of the patients in recent years. However, the prevalence of cardiovascular adverse events (CVAEs) in MM had been increasing recently. CVAEs in MM patients are an important problem that we should focus on. Clinical tools for prognostication and risk-stratification are needed. Patients and methods This is a retrospective study that included patients who were newly diagnosed with multiple myeloma (NDMM) in Shanghai Changzheng Hospital and Affiliated Jinhua Hospital, Zhejiang University School of Medicine from June 2018 to July 2020. A total of 253 patients from two medical centers were divided into training cohort and validation cohort randomly. Univariable analysis of the baseline factors was performed using CVAEs endpoints. Multivariable analysis identified three factors for a prognostic model that was validated in internal validation cohorts. Results Factors independently associated with CVAEs in NDMM were as follows: age>61 years old, high level of baseline office blood pressure, and left ventricular hypertrophy (LVH). Age contributed 2 points, and the other two factors contributed 1 point to a prognostic model. The model distinguished the patients into three groups: 3-4 points, high risk; 2 points, intermediate risk; 0-1 point, low risk. These groups had significant difference in CVAEs during follow-up days in both training cohort (p<0.0001) and validation cohort (p=0.0018). In addition, the model had good calibration. The C-indexes for the prediction of overall survival of CVAEs in the training and validation cohorts were 0.73 (95% CI, 0.67-0.79) and 0.66 (95% CI, 0.51-0.81), respectively. The areas under the receiver operating characteristic curve (AUROCs) of the 1-year CVAEs probability in the training and validation cohorts were 0.738 and 0.673, respectively. The AUROCs of the 2-year CVAE probability in the training and validation cohorts were 0.722 and 0.742, respectively. The decision-curve analysis indicated that the prediction model provided greater net benefit than the default strategies of providing assessment or not providing assessment for all patients. Conclusion A prognostic risk prediction model for predicting CVAEs risk of NDMM patients was developed and internally validated. Patients at increased risk of CVAEs can be identified at treatment initiation and be more focused on cardiovascular protection in the treatment plan.
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Affiliation(s)
- Shuai Yuan
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-Yi Zhou
- Department of Nuclear Radiation Injury Protection and Treatment Department, Naval Medical Center, Naval Medical University, Shanghai, China
| | - Ben-Zhao Yang
- Department of Cardiology, Naval Medical Center, Naval Medical University, Shanghai, China
| | - Zhong-Lei Xie
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting-Jun Zhu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Hui-Xian Hu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
- *Correspondence: Hui-Xian Hu, ; Rong Li,
| | - Rong Li
- Department of Nuclear Radiation Injury Protection and Treatment Department, Naval Medical Center, Naval Medical University, Shanghai, China
- Department of Hematology, The Myeloma and Lymphoma Center, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Hui-Xian Hu, ; Rong Li,
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12
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Buck B, Kellett E, Addison D, Vallakati A. Carfilzomib-induced Cardiotoxicity: An Analysis of the FDA Adverse Event Reporting System (FAERS). J Saudi Heart Assoc 2022; 34:134-141. [PMID: 36127934 PMCID: PMC9458320 DOI: 10.37616/2212-5043.1311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 11/20/2022] Open
Abstract
Background Carfilzomib and other proteasome inhibitors (PIs) have revolutionized treatment of multiple myeloma (MM). PIs have proven to be highly effective, but are associated with significant cardiovascular adverse events (AEs). No prior study has compared the cardiotoxicity of carfilzomib against other PI’s and all other classes of medications. Objectives The purpose of this study is to characterize the cardiotoxicity of carfilzomib with respect to other PIs and all classes of medications using the US Food and Drug Administration Adverse Events Reporting System (FAERS) database and to define the observed cardiotoxicity profile. Methods The FAERS database was queried between years 2017 and 2020 to identify AEs associated with PIs. Data extracted included concomitant medications used, type and severity of AEs and patient characteristics including age, sex, and time from medication initiation to adverse event. Cardiotoxicities assessed included acute myocardial infarction, heart failure, and supraventricular tachycardia. The reporting odds ratio (ROR) and information component assessed the strength of association between PIs and cardiotoxicity. Results Over the study period, 21,026 adverse events were reported in patients taking carfilzomib among 55,195 total adverse events in patients taking PI’s were identified from 6,548,048 total events reported in the FAERS database. The most common AE associated with carfilzomib was development of heart failure (1116 adverse events); disproportionality analysis revealed a stronger association with hypertension and QT prolongation with carfilzomib than other PI’s. Conclusions While they have demonstrated efficacy and revolutionized treatment of MM, carfilzomib and other PI’s are associated with cardiotoxicities.
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Affiliation(s)
- Benjamin Buck
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric Kellett
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Addison
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA.,Division of Cardiovascular Medicine, Section of Cardio-Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ajay Vallakati
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA.,Division of Cardiovascular Medicine, Section of Heart Failure, Ohio State University Wexner Medical Center, Columbus, OH, USA
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13
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Comerford C, Glavey S, Quinn J, O’Sullivan JM. The role of VWF/FVIII in thrombosis and cancer progression in multiple myeloma and other hematological malignancies. J Thromb Haemost 2022; 20:1766-1777. [PMID: 35644028 PMCID: PMC9546473 DOI: 10.1111/jth.15773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/11/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
Cancer associated thrombosis (CAT) is associated with significant morbidity and mortality, highlighting an unmet clinical need to improve understanding of the pathophysiology of CAT. Multiple myeloma (MM) is associated with one of the highest rates of thrombosis despite widespread use of thromboprophylactic agents. The pathophysiology of thrombosis in MM is multifactorial and patients with MM appear to display a hypercoagulable phenotype with potential contributory factors including raised von Willebrand factor (VWF) levels, activated protein C resistance, impaired fibrinolysis, and abnormal thrombin generation. In addition, the toxic effect of anti-myeloma therapies on the endothelium and contribution to thrombosis has been widely described. Elevated VWF/factor VIII (FVIII) plasma levels have been reported in heterogeneous cohorts of patients with MM and other hematological malignancies. In specific studies, high plasma VWF levels have been shown to associate with VTE risk and reduced overall survival. While the mechanisms underpinning this remain unclear, dysregulation of the VWF and A Disintegrin And Metalloprotease Thrombospondin type 1, motif 13 (ADAMTS-13) axis is evident in certain solid organ malignancies and correlates with advanced disease and thrombosis. Furthermore, thrombotic microangiopathic conditions arising from deficiencies in ADAMTS-13 and thus an accumulation of prothrombotic VWF multimers have been reported in patients with MM, particularly in association with specific myeloma therapies. This review will discuss current evidence on the pathophysiological mechanisms underpinning thrombosis in MM and in particular summarize the role of VWF/FVIII in hematological malignancies with a focus on thrombotic risk and emerging evidence for contribution to disease progression.
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Affiliation(s)
- Claire Comerford
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
- Department of HaematologyBeaumont HospitalDublinIreland
| | - Siobhan Glavey
- Department of HaematologyBeaumont HospitalDublinIreland
- School of PathologyRoyal College of Surgeons in IrelandDublinIreland
| | - John Quinn
- Department of HaematologyBeaumont HospitalDublinIreland
- School of MedicineRoyal College of Surgeons in IrelandDublinIreland
| | - Jamie M. O’Sullivan
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
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14
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Yin X, Fan F, Zhang B, Hu Y, Sun C. Cardiovascular-specific mortality among multiple myeloma patients: a population-based study. Ther Adv Hematol 2022; 13:20406207221086755. [PMID: 35387110 PMCID: PMC8978329 DOI: 10.1177/20406207221086755] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/23/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction: Multiple myeloma (MM) survival has greatly improved in recent decades. MM is usually diagnosed at a median age of 66–70 years. MM patients do not necessarily die from primary cancer, so cardiovascular health may be a key factor threatening long-term survival. This study was designed to explore the cardiovascular disease mortality (CVM) trends in MM patients and compare them with those in the general population. Methods: In total, 88,328 MM patients from the Surveillance, Epidemiology, and End Results (SEER) database (1975–2016) were included. Standardized mortality ratios (SMRs) were used to assess CVM risk. Results: The CVM risk was significantly higher in MM patients than in the general population (SMR, 1.84 (95% CI, 1.78–1.89)). MM patients had the highest CVM SMR, at 2.62 (95% CI, 2.49–2.75), in the first year after diagnosis, and it decreased over the follow-up period. Over the study period, the incidence of CVM continued to decrease in MM patients diagnosed at age 65–74 (APC, −1.2% (95% CI, −1.9% to −0.4%)) and ⩾75 years (APC, −1.9% (95% CI, −2.6% to −1.2%)) but not younger. CVM was the second-most common cause of death in patients ⩾75 years. In only MM case analyses, male sex, Black race, older age at diagnosis, and earlier year of diagnosis were poor prognostic factors for heart-specific mortality. Conclusion: The CVM risk in MM patients was significantly higher than that in the general population. To improve survival, cardiovascular health should receive attention upon diagnosis.
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Affiliation(s)
- Xuejiao Yin
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, China
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fengjuan Fan
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyan Sun
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan 430022, China
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15
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Muramatsu A, Kobayashi T, Kawaji-Kanayama Y, Uchiyama H, Sasaki N, Uoshima N, Nakao M, Takahashi R, Shimura K, Kaneko H, Kiyota M, Wada K, Chinen Y, Hirakawa K, Fuchida SI, Shimazaki C, Mizutani S, Tsukamoto T, Shimura Y, Taniwaki M, Teramukai S, Kuroda J. Pretreatment serum level of interleukin-6 predicts carfilzomib-induced hypertension in relapsed/refractory multiple myeloma. Leuk Lymphoma 2022; 63:1678-1685. [PMID: 35147475 DOI: 10.1080/10428194.2022.2038373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Carfilzomib (CFZ) constitutes powerful combinatory therapy for relapsed/refractory multiple myeloma (RRMM); however, cardiovascular adverse events (CVAEs) have been shown as major treatment obstacles with the use of CFZ. Along with our multi-institutional prospective observational study by the Kyoto Clinical Hematology Study Group on the efficacy and safety of CFZ-based treatments (UMIN000025108), we here performed an ad hoc analysis of CFZ-related CVAEs in 50 patients with RRMM. We analyzed the association between CFZ-related CVAEs and pre-planned examinations, including patients' background, electrocardiographic findings, echocardiographic findings, and serum/plasma levels of 18 potential candidate biomarkers. The common CVAEs were hypertension (42%), arrhythmia (14%), and prolongation of QT corrected interval (10%), whereas no serious CVAEs occurred. The pretreatment serum level of interleukin-6 was identified as a significant risk factor for CFZ-related hypertension. This study revealed hypertension as the most frequent CFZ-related CVAE and suggested that baseline serum interleukin-6 is a useful predictor for CFZ-induced hypertension.
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Affiliation(s)
- Ayako Muramatsu
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuka Kawaji-Kanayama
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hitoji Uchiyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nana Sasaki
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Nobuhiko Uoshima
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Mitsushige Nakao
- Department of Internal Medicine, Otsu Municipal Hospital, Shiga, Japan
| | - Ryoichi Takahashi
- Department of Hematology, Omihachiman Community Medical Center, Shiga, Japan
| | - Kazuho Shimura
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Hiroto Kaneko
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan
| | - Miki Kiyota
- Department of Hematology, Matsushita Memorial Hospital, Osaka, Japan
| | - Katsuya Wada
- Department of Hematology, Matsushita Memorial Hospital, Osaka, Japan
| | - Yoshiaki Chinen
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Hematology, Fukuchiyama City Hospital, Kyoto, Japan
| | - Koichi Hirakawa
- Department of Hematology, Fukuchiyama City Hospital, Kyoto, Japan
| | - Shin-Ichi Fuchida
- Department of Hematology, Kyoto Kuramaguchi Medical Center, Japan Community Health Care Organization, Kyoto, Japan
| | - Chihiro Shimazaki
- Department of Hematology, Kyoto Kuramaguchi Medical Center, Japan Community Health Care Organization, Kyoto, Japan
| | - Shinsuke Mizutani
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Tsukamoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masafumi Taniwaki
- Department of Hematology, Aiseikai Yamashina Hospital, Kyoto, Japan.,Center for Molecular Diagnostic and Therapeutics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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16
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DeStefano CB, Gibson SJ, Sperling AS, Richardson PG, Ghobrial I, Mo CC. The emerging importance and evolving understanding of clonal hematopoiesis in multiple myeloma. Semin Oncol 2022; 49:19-26. [DOI: 10.1053/j.seminoncol.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/09/2022] [Indexed: 12/19/2022]
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17
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López-Candales A, Habash F, Vallurupalli S. Increased Prevalence of Fragmented QRS in Randomly Selected Group of Multiple Myeloma Patients: A Pilot Study to Assess Prevalence. Cureus 2021; 13:e20635. [PMID: 35106200 PMCID: PMC8786585 DOI: 10.7759/cureus.20635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/18/2022] Open
Abstract
The presence of fragmented QRS (fQRS) on surface electrocardiograms (ECGs) has been associated with the myocardial scar in certain cardiac conditions and has been proposed as a potential marker of adverse cardiac outcomes. Since myocardial fibrosis not only has been recognized as a side effect of certain cancer therapies but also, fQRS have been shown in some breast cancer and lymphoma survivors post-chemotherapy treatment, we decided to investigate if fQRS could also be seen in multiple myeloma (MM) patients since this association has never been described. For this pilot study, we analyzed ECGs from 137 randomly selected MM patients during different stages of their treatment, and fRQS was found in 42% of these cases. The prevalence was much higher than the reported prevalence for the general population (19.0%) but closer to that reported for patients with myocardial infarction (39.5%). We also found that female MM patients are more commonly affected than women in the general population. Based on this small random sampling analysis, fQRS appears highly prevalent among unselected MM patients. This novel finding of fQRS in MM patients certainly adds to the growing data of cases among different cancer patients, opening the door to conduct larger prospective studies that undoubtedly will help to create a more robust database regarding the potential utility of this ECG abnormality.
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18
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Benz DC, Buechel RR, Dorbala S. (18)F-sodium fluoride PET in multiple myeloma: Linking cancer to atherosclerosis? J Nucl Cardiol 2021; 28:3055-3057. [PMID: 33398792 DOI: 10.1007/s12350-020-02447-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- Department of Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland.
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Radiology, CV Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
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19
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Fontes Oliveira M, Naaktgeboren WR, Hua A, Ghosh AK, Oakervee H, Hallam S, Manisty C. Optimising cardiovascular care of patients with multiple myeloma. Heart 2021; 107:1774-1782. [PMID: 33820757 DOI: 10.1136/heartjnl-2020-318748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022] Open
Abstract
Multiple myeloma (MM) is the third most common haematological malignancy, with increasing prevalence over recent years. Advances in therapy have improved survival, changing the clinical course of MM into a chronic condition and meaning that management of comorbidities is fundamental to improve clinical outcomes. Cardiovascular (CV) events affect up to 7.5% of individuals with MM, due to a combination of patient, disease and treatment-related factors and adversely impact survival. MM typically affects older people, many with pre-existing CV risk factors or established CV disease, and the disease itself can cause renal impairment, anaemia and hyperviscosity, which exacerabate these further. Up to 15% of patients with MM develop systemic amyloidosis, with prognosis determined by the extent of cardiac involvement. Management of MM generally involves administration of multiple treatment lines over several years as disease progresses, with many drug classes associated with adverse CV effects including high rates of venous and arterial thrombosis alongside heart failure. Recommendations for holistic management of patients with MM now include routine baseline risk stratification including ECG and echocardiography and administration of thromboprophylaxis drugs for patients treated with immunomodulatory drugs. Close surveillance of high-risk patients with collaboration between haematology and cardiology is required, with prompt investigation in the event of CV symptoms, in order to identify and treat complications early. Decisions regarding discontinuation of cardiotoxic therapies should be made in a multidisciplinary setting, taking into account the severity of the complication, prognosis, expected benefits and the availability of effective alternatives.
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Affiliation(s)
- Marta Fontes Oliveira
- Department of Cardio-Oncology, St Bartholomew's Hospital, London, UK
- Department of Cardiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Willeke R Naaktgeboren
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Alina Hua
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Arjun K Ghosh
- Department of Cardio-Oncology, St Bartholomew's Hospital, London, UK
- Hatter Institute, London, UK
| | - Heather Oakervee
- Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK
| | - Simon Hallam
- Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Charlotte Manisty
- Department of Cardio-Oncology, St Bartholomew's Hospital, London, UK
- University College London, London, UK
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20
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Wang J, Tang M, Long Y, Song J, Chen L, Wang M, Li Y, Sun C, Yan Y. Prognostic Potential of Heart Rate and Hypertension in Multiple Myeloma Patients. Front Cardiovasc Med 2021; 8:681484. [PMID: 34646869 PMCID: PMC8502919 DOI: 10.3389/fcvm.2021.681484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023] Open
Abstract
Background: The prognosis of patients with multiple myeloma (MM) is variable and partly depends on their cardiovascular status. The presence of arrhythmias can lead to worse outcomes. Therefore, this study aimed to evaluate the potential of heart rate (HR) and hypertension in predicating the outcomes of MM patients. Methods: This study retrospectively enrolled patients with MM between January 1, 2010, and December 31, 2018, at the First Affiliated Hospital of Xi'an Jiaotong University. The endpoint was all-cause mortality. The Pearson's chi-square test was used to assess the association between hypertension and outcomes. Univariate and multivariate Cox proportional hazards models were developed to evaluate the relationship between HR and all-cause mortality. Results: A total of 386 patients were included. The mean HR was 83.8 ± 23.1 beats per minute (bpm). Patients with HR >100 bpm had a higher all-cause mortality (79.4%, 50/63) than those with 60 ≤ HR ≤ 100 bpm (39.9%, 110/276) and <60 bpm (19.1%, 9/47) (p < 0.001). Subgroup analysis based on the International Staging System and sex revealed similar relationships (p < 0.01). When stratified by age, patients with HR >100 bpm had higher all-cause mortality than those with a lower HR when age was <65 years or 65-75 years (p < 0.001) but not >75 years. The proportion of patients with hypertension was 54.7% (211/386). However, hypertension was not associated with all-cause mortality in MM patients (χ2=1.729, p > 0.05). MM patients with HR >100 bpm had the highest all-cause mortality. Conclusions: The prognostic potential of HR may be useful in aiding risk stratification and promoting the management of these patients.
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Affiliation(s)
- Jie Wang
- Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Manyun Tang
- Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yunxiang Long
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingzhuo Song
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Limei Chen
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengchang Wang
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yongxin Li
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Chaofeng Sun
- Atrial Fibrillation Centre and Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang Yan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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21
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Tantawy M, Chekka LM, Huang Y, Garrett TJ, Singh S, Shah CP, Cornell RF, Baz RC, Fradley MG, Waheed N, DeRemer DL, Yuan L, Langaee T, March K, Pepine CJ, Moreb JS, Gong Y. Lactate Dehydrogenase B and Pyruvate Oxidation Pathway Associated With Carfilzomib-Related Cardiotoxicity in Multiple Myeloma Patients: Result of a Multi-Omics Integrative Analysis. Front Cardiovasc Med 2021; 8:645122. [PMID: 33996940 PMCID: PMC8116486 DOI: 10.3389/fcvm.2021.645122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/02/2021] [Indexed: 01/20/2023] Open
Abstract
Multiple myeloma (MM) is the second most frequent hematologic cancer in the United States. Carfilzomib (CFZ), an irreversible proteasome inhibitor being used to treat relapsed and refractory MM, has been associated with cardiotoxicity, including heart failure. We hypothesized that a multi-omics approach integrating data from different omics would provide insights into the mechanisms of CFZ-related cardiovascular adverse events (CVAEs). Plasma samples were collected from 13 MM patients treated with CFZ (including 7 with CVAEs and 6 with no CVAEs) at the University of Florida Health Cancer Center. These samples were evaluated in global metabolomic profiling, global proteomic profiling, and microRNA (miRNA) profiling. Integrative pathway analysis was performed to identify genes and pathways differentially expressed between patients with and without CVAEs. The proteomics analysis identified the up-regulation of lactate dehydrogenase B (LDHB) [fold change (FC) = 8.2, p = 0.01] in patients who experienced CVAEs. The metabolomics analysis identified lower plasma abundance of pyruvate (FC = 0.16, p = 0.0004) and higher abundance of lactate (FC = 2.4, p = 0.0001) in patients with CVAEs. Differential expression analysis of miRNAs profiling identified mir-146b to be up-regulatein (FC = 14, p = 0.046) in patients with CVAE. Pathway analysis suggested that the pyruvate fermentation to lactate pathway is associated with CFZ-CVAEs. In this pilot multi-omics integrative analysis, we observed the down-regulation of pyruvate and up-regulation of LDHB among patients who experienced CVAEs, suggesting the importance of the pyruvate oxidation pathway associated with mitochondrial dysfunction. Validation and further investigation in a larger independent cohort are warranted to better understand the mechanisms of CFZ-CVAEs.
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Affiliation(s)
- Marwa Tantawy
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Lakshmi Manasa Chekka
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Yimei Huang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Timothy J Garrett
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Sonal Singh
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Chintan P Shah
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Robert F Cornell
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Preston Research Building, Nashville, TN, United States
| | - Rachid C Baz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Nida Waheed
- Department of Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | | | - Lihui Yuan
- Department of Pharmacodynamics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Keith March
- Division of Cardiovascular Medicine, Department of Medicine and Center for Regenerative Medicine, University of Florida, Gainesville, FL, United States
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine and Center for Regenerative Medicine, University of Florida, Gainesville, FL, United States
| | - Jan S Moreb
- Novant Health Forsyth Medical Center, Hematology, Transplantation, and Cellular Therapy Division, Winston-Salem, NC, United States
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States.,UF Health Cancer Center, Gainesville, FL, United States.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, United States
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22
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Ptushkin VV, Mueller M. Analysis of the effectiveness of multiple myeloma treatment based on the clinical experience of European countries. TERAPEVT ARKH 2021; 93:404-414. [DOI: 10.26442/00403660.2021.04.200682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
Aim. The main aim of this study was to model the effectiveness of multiple myeloma (MM) therapy using machine learning, which was based on the analysis of various methods of MM treatment, a number of prognostic factors and their results in the daily routine clinical practice of medical centers in European countries.
Materials and methods. The present study was retrospective, non-interventional, multicenter. A structured database of MM patients provided by the Oncology Information service (O.I.s.) was used for the study. Registration took place in medical institutions in eight countries: Austria, Belgium, Switzerland, Germany, Spain, France, Greece and Great Britain.
Results. In total, 57% of men and 43% of women were analyzed in the base of 6074 patients with MM. The median age was 71 years. The median follow-up time along the lines was 387 days. High-risk cytogenetics are represented in 15% of cases. The efficacy endpoint was the best response to each line of therapy, as measured by time to death (TTD) as an indirect indicator of overall survival and time to next treatment (TTNT) as an indirect indicator of progression-free survival. The median TTD and TTNT were 730 and 399 days respectively. After a multi-step selection process, characteristics with the greatest importance for the therapy prognosis were selected: age at the beginning of therapy, line of therapy, time after MM verification, ECOG (Eastern Cooperative Oncology Group), cytogenetic risk, transplant eligibible or not, TTNT after the previous line of therapy, therapy regimen.
Discussion. To continue the study it is necessary to analyze literature data and compare with real practice. Also analysis and comparison with Russian data on the treatment of patients with MM is required.
Conclusion. The analysis of the presented data provides a basis for modeling a tool for assessing the effectiveness of MM therapy (prognosis of TTD and TTNT) for each patient, based on a number of prognostic factors and the results of routine clinical practice in various medical centers in European countries.
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23
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Pancheri E, Guglielmi V, Wilczynski GM, Malatesta M, Tonin P, Tomelleri G, Nowis D, Vattemi G. Non-Hematologic Toxicity of Bortezomib in Multiple Myeloma: The Neuromuscular and Cardiovascular Adverse Effects. Cancers (Basel) 2020; 12:cancers12092540. [PMID: 32906684 PMCID: PMC7563977 DOI: 10.3390/cancers12092540] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Multiple myeloma (MM) is a still uncurable tumor of mainly elderly patients originating from the terminally differentiated B cells. Introduction to the treatment of MM patients of a new class of drugs called proteasome inhibitors (bortezomib followed by carfilzomib and ixazomib) significantly improved disease control. Proteasome inhibitors interfere with the major mechanism of protein degradation in a cell leading to the severe imbalance in the protein turnover that is deadly to MM cells. Currently, these drugs are the mainstream of MM therapy but are also associated with an increased rate of the injuries to multiple organs and tissues. In this review, we summarize the current knowledge on the molecular mechanisms of the first-in-class proteasome inhibitor bortezomib-induced disturbances in the function of peripheral nerves and cardiac and skeletal muscle. Abstract The overall approach to the treatment of multiple myeloma (MM) has undergone several changes during the past decade. and proteasome inhibitors (PIs) including bortezomib, carfilzomib, and ixazomib have considerably improved the outcomes in affected patients. The first-in-class selective PI bortezomib has been initially approved for the refractory forms of the disease but has now become, in combination with other drugs, the backbone of the frontline therapy for newly diagnosed MM patients, as well as in the maintenance therapy and relapsed/refractory setting. Despite being among the most widely used and highly effective agents for MM, bortezomib can induce adverse events that potentially lead to early discontinuation of the therapy with negative effects on the quality of life and outcome of the patients. Although peripheral neuropathy and myelosuppression have been recognized as the most relevant bortezomib-related adverse effects, cardiac and skeletal muscle toxicities are relatively common in MM treated patients, but they have received much less attention. Here we review the neuromuscular and cardiovascular side effects of bortezomib. focusing on the molecular mechanisms underlying its toxicity. We also discuss our preliminary data on the effects of bortezomib on skeletal muscle tissue in mice receiving the drug.
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Affiliation(s)
- Elia Pancheri
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Valeria Guglielmi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Grzegorz M. Wilczynski
- Laboratory of Molecular and Systemic Neuromorphology, Department of Neurophysiology Warsaw, Nencki Institute of Experimental Biology, 02-093 Warsaw, Poland;
| | - Manuela Malatesta
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Anatomy and Histology, University of Verona, 37134 Verona, Italy;
| | - Paola Tonin
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Giuliano Tomelleri
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Dominika Nowis
- Department of Immunology, Medical University of Warsaw, 02-093 Warsaw, Poland;
- Laboratory of Experimental Medicine, Medical University of Warsaw, 02-093 Warsaw, Poland
| | - Gaetano Vattemi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
- Correspondence:
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24
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Mair M, Straka C, Buratti T, Tauber M, Mitterer M, Fong D. Clinical outcomes and prognostic factors in patients with multiple myeloma in South Tyrol: a retrospective single-center analysis. Ann Hematol 2020; 99:1031-1040. [PMID: 32140891 DOI: 10.1007/s00277-020-03969-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (HD-ASCT) as well as the introduction of novel agents (NA) significantly improved survival for patients with multiple myeloma (MM). A total of 150 unselected newly diagnosed MM patients treated at our institution from 1998 to 2017 were retrospectively analyzed. Median age at diagnosis was 69 years (range 33-93 years) with a median follow-up of 48.6 months. The median overall survival (OS) for the entire cohort was 60.7 months (range 0.3-280.1). Patients who received frontline HD-ASCT (p < 0.01) or NA-based first-line treatment (p = 0.043) had a significantly better OS. According to the revised Myeloma Comorbidity Index (R-MCI), patients were defined as fit (36.5%), intermediate-fit (44.5%), or frail (19%) with a significant difference in OS between these categories (p < 0.01). Multivariate analysis revealed R-MCI as an independent prognostic factor for OS (p < 0.01). Presence of subclinical amyloid deposits (A+) was detected in 18 out of 66 patients (27.3%) and significantly correlated with a serum free light chain (sFLC) ratio ≥ 100 (p = 0.01) and bone marrow plasma cell infiltration > 60% (p = 0.04). Furthermore, patients with A+ had significantly worse OS compared with their counterparts (p = 0.048). Our results corroborate the efficacy of both early HD-ASCT and the use of new agents as initial therapy of MM patients in "real-world" daily clinical practice. The R-MCI is an easily applicable tool to stratify MM patients and may support treatment decisions. The prognostic value of subclinical amyloid deposition should be validated within prospective studies.
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Affiliation(s)
- Maximilian Mair
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Christian Straka
- Hematology, Oncology and Infectiology, Munich Schwabing Hospital, Munich, Germany
| | - Thomas Buratti
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy
| | - Martina Tauber
- Department of Pathology, Bolzano Regional Hospital, Bolzano, Italy
| | - Manfred Mitterer
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy
| | - Dominic Fong
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy.
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25
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Chari A, Romanus D, Palumbo A, Blazer M, Farrelly E, Raju A, Huang H, Richardson P. Randomized Clinical Trial Representativeness and Outcomes in Real-World Patients: Comparison of 6 Hallmark Randomized Clinical Trials of Relapsed/Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:8-17.e16. [PMID: 31722839 DOI: 10.1016/j.clml.2019.09.625] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/02/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Concern has been increasing in oncology regarding randomized clinical trial (RCT) eligibility limiting the generalizability of the findings to real-world populations. Using a large US electronic health record database, we investigated the real-world generalizability of the findings from recent RCTs for relapsed and/or refractory multiple myeloma (RRMM). PATIENTS AND METHODS Patients with RRMM initiating second-to fourth-line therapy with the control arm of the following RCTs were retrospectively identified and categorized as "RCT eligible" or "RCT ineligible" according to the eligibility criteria: (1) Rd (lenalidomide, dexamethasone)-ASPIRE, TOURMALINE-MM1, POLLUX, and ELOQUENT-2; and (2) Vd (bortezomib, dexamethasone)-CASTOR and ENDEAVOR. Predictors of RCT ineligibility and overall survival were analyzed using logistic regression and Cox regression analysis. RESULTS Variations in the individual trial ineligibility rates were noted, with up to 72.3% (range, 47.9%-72.3%) of patients not meeting the eligibility criteria for 1 of the 6 hallmark RCTs (n = 788 for Rd; n = 477 for Vd). Other malignancies, cardiovascular disease, acute infection, and renal dysfunction were the common reasons for ineligibility. Advanced age, Charlson comorbidity score of ≥ 2, later therapy lines (3-4), and refractory status to the previous line were independently predictive of RCT ineligibility. RCT-ineligible versus RCT-eligible patients had a significantly greater mortality risk (hazard ratio, Rd, 1.46; Vd, 1.51). CONCLUSION Most real-world patients with RRMM were ineligible for the hallmark RCTs. The eligibility rates varied across the RCTs, underlining the flawed nature of cross-study comparisons without RCT validation. Overall survival was significantly affected by the inability to meet the criteria, highlighting the limited generalizability of the RCT results. Greater efforts are required to broaden the eligibility criteria to reflect real-world clinical characteristics and narrow the gap between RCT efficacy and the observed effectiveness in real-world patients with RRMM.
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Affiliation(s)
- Ajai Chari
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Dorothy Romanus
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Marlo Blazer
- Scientific Consulting, Xcenda, LLC, Palm Harbor, FL
| | | | - Aditya Raju
- Scientific Consulting, Xcenda, LLC, Palm Harbor, FL
| | - Hui Huang
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Dana Farber Cancer Institute, Boston, MA
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26
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Durer C, Durer S, Lee S, Chakraborty R, Malik MN, Rafae A, Zar MA, Kamal A, Rosko N, Samaras C, Valent J, Chaulagain C, Anwer F. Treatment of relapsed multiple myeloma: Evidence-based recommendations. Blood Rev 2019; 39:100616. [PMID: 31500848 DOI: 10.1016/j.blre.2019.100616] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/14/2019] [Accepted: 08/30/2019] [Indexed: 12/01/2022]
Abstract
The practice of choosing the next best therapy for patients with relapsed and/or refractory multiple myeloma (RRMM) is becoming increasingly complex. There is no clear consensus regarding the best treatment sequence for RRMM. With the approval of novel proteasome inhibitors (ixazomib and carfilzomib), immunomodulatory agents (pomalidomide), monoclonal antibodies (daratumumab and elotuzumab), and other targeted therapies, multiple combination regimens utilizing these agents are being studied with the goal of enhancing disease control, prolonging progression-free survival, and improving overall survival. We, herein, describe a review of FDA-approved regimens for RRMM patients and offer a paradigm in selecting subsequent treatment regimens, focusing on patient specific morbidity, treatment toxicity, and disease-specific characteristics.
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Affiliation(s)
- Ceren Durer
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Seren Durer
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Sarah Lee
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Rajshekhar Chakraborty
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Abdul Rafae
- Department of Medicine, McLaren/Michigan State University, Flint, MI, USA
| | - Muhammad Abu Zar
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ahmad Kamal
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nathaniel Rosko
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chakra Chaulagain
- Department of Hematology and Medical Oncology, Cleveland Clinic, Weston, FL, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA.
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27
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Milan A, Bruno G, Maffei I, Iannaccone A, Ravera A, Schiavone D, Veglio F. Arterial Hypertension and Multiple Myeloma: Physiopathology and Cardiovascular Risk and 'Practical' Indications in Patients Receiving Carfilzomib. Curr Hypertens Rev 2019; 15:47-53. [PMID: 29886833 DOI: 10.2174/1573402114666180611110547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 01/08/2023]
Abstract
The introduction of carfilzomib in the treatment of relapsing and refractory multiple myeloma has allowed a significant increase in survival. The most frequent adverse effect of Carfilzomib treatment is arterial hypertension, even though the exact physiopathological mechanism are still unclear. MM patients, on the other hand, often present significant cardiovascular risk factors and comorbidities. Uncontrolled hypertension is frequently the cause of cardiovascular complications. It has been estimated that up to 50% of subjects in the general population are unaware of their hypertensive condition and only half of those who are aware of this risk factor present good control of blood pressure. Although the management of arterial hypertension is clearly important in reducing the risk of cardiovascular events, and is well described by the current guidelines, no clear indications are provided on how to approach and treat specifically MM patients undergoing treatment with proteasome inhibitors. The aim of our work is to summarize a practical approach to the stratification of cardiovascular risk of hypertensive in patients who are candidates for or actively treated with carfilzomib for refractory multiple myeloma (MMR). MM patients eligible for carfilzomib treatment should preliminary undergo a careful cardiovascular risk stratification. Perspective studies will help to better identify the specific risk factors that should be considered and treated in these patients.
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Affiliation(s)
- Alberto Milan
- Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giulia Bruno
- Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Ilaria Maffei
- Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Andrea Iannaccone
- Unit of Geriatrics and Metabolic Bone Diseases, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Agnese Ravera
- Unit of Geriatrics and Metabolic Bone Diseases, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Domenica Schiavone
- Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Franco Veglio
- Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Citta della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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28
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Hypertension in hematologic malignancies and hematopoietic cell transplantation: An emerging issue with the introduction of novel treatments. Blood Rev 2019; 35:51-58. [DOI: 10.1016/j.blre.2019.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/29/2018] [Accepted: 03/12/2019] [Indexed: 12/12/2022]
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29
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Patel VG, Cornell RF. Cardiovascular Complications Associated with Multiple Myeloma Therapies: Incidence, Pathophysiology, and Management. Curr Oncol Rep 2019; 21:29. [PMID: 30834998 DOI: 10.1007/s11912-019-0784-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Multiple myeloma is a common hematologic malignancy characterized by recurrent relapsing disease course requiring use of various therapies. Over the past few decades, significant advancements in the treatment of myeloma have occurred including routine use of proteasome inhibitors and immunomodulatory drugs. These have effectively improved survival; however, some also have increased risk of cardiovascular toxicity. Here, we will review the incidence, pathophysiology, and management of cardiovascular complications associated with antimyeloma agents. RECENT FINDINGS Cardiovascular complications associated with myeloma treatment are common. These cardiovascular complications include accelerated hypertension, ischemic heart disease, congestive heart failure, arrhythmia, pulmonary hypertension, venous thromboembolism, and arterial thromboembolism. Thromboprophylactic strategies during treatment with immunomodulatory agents and screening strategies to detect changes in myocardial function prior to the development of overt heart failure have occurred. Cardiovascular complications associated with proteasome inhibitors and immunomodulatory drugs are an important component in supportive care of patients with myeloma. The incidence of cardiotoxicity is high, and, as such, early intervention and collaborative efforts between cardiologists and oncologists to mitigate and effectively manage these complications are imperative. Additional studies are needed to clarify the underlying pathophysiology and evaluate effective strategies for prevention and treatment.
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Affiliation(s)
- Vivek G Patel
- Department of Internal Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Robert F Cornell
- Department of Internal Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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Fraz MA, Warraich FH, Warraich SU, Tariq MJ, Warraich Z, Khan AY, Usman M, Ijaz A, Tenneti P, Mushtaq A, Akbar F, Shahid Z, Ali Z, Fazeel HM, Rodriguez C, Nasar A, McBride A, Anwer F. Special considerations for the treatment of multiple myeloma according to advanced age, comorbidities, frailty and organ dysfunction. Crit Rev Oncol Hematol 2019; 137:18-26. [PMID: 31014512 DOI: 10.1016/j.critrevonc.2019.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 02/24/2019] [Indexed: 12/30/2022] Open
Abstract
Multiple Myeloma (MM) is primarily a disease of old age with a median age of sixty-nine years at diagnosis. The development of novel therapies for induction and use of autologous stem cell transplantation has resulted in improved clinical outcomes and better quality of life for MM patients. Elderly patients, comprising the majority of MM population, have a higher incidence of age-related comorbidities, frailty and organ dysfunction which complicates the coordination of treatment and limits the selection of therapies. Even in the era of multiple chemotherapeutic options, the clinical heterogeneity of the myeloma patients' demands personalized treatments which often require dose-adjustments or dose delays. The use of reduced-dose regimens and various comorbidity indices has improved clinical outcome and regimen tolerability in MM patients with renal, neurological and bone abnormalities. We focus on advancements in the treatment of multiple myeloma with the goal to guide clinicians towards patient-specific management.
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Affiliation(s)
- Muhammad Asad Fraz
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Faiza Hassan Warraich
- Department of Internal Medicine, McLaren-Flint Medical Center, Flint, MI, 48532, United States
| | - Sami Ullah Warraich
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Muhammad Junaid Tariq
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Zabih Warraich
- Department of Internal Medicine, United Health Services Wilson Memorial Regional Medical Center, Johnson City, NY, 13790, United States
| | - Ali Younas Khan
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Muhammad Usman
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Awais Ijaz
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Pavan Tenneti
- Department of Medicine, Banner University Medical Center, Tucson, AZ, 85724, United States
| | - Adeela Mushtaq
- Department of Medicine, University of Pittsburgh Medical Center, McKeesport, PA, 15132, United States
| | - Faisal Akbar
- Department of Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, 27157, United States
| | - Zaina Shahid
- Department of Medicine, Wilkes Medical Center- Wake Forest Baptist Health, Wilkesboro, NC, 28659, United States
| | - Zeeshan Ali
- Department of Medicine, Southern Arizona Veterans Affairs Health Care System, Tucson, AZ, 85723, United States
| | - Hafiz Muhammad Fazeel
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Cesar Rodriguez
- Department of Hematology Oncology, Wake Forest Baptist Medical Comprehensive Cancer Center, Winston Salem, NC, 27157, United States
| | - Aboo Nasar
- Department of Geriatrics, Tri-City Medical Center, 4002 Vista Way, Oceanside, CA 92056, United States
| | - Ali McBride
- Department of Pharmacy, The University of Arizona Cancer Center, Tucson, AZ, 85737, United States
| | - Faiz Anwer
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States; Taussig Cancer Center, Department of Hematology, Medical Oncology, Cleveland Clinic, Cleveland, OH, 44195, United States.
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Serra W, Fantin A, Longo C, Rabia G, De Rosa F, Plenteda C, Re F, Crisafulli E, Chetta A. Carfilzomib: A Tale of a Heartbreaking Moment: Case Report and Concise Review of the Literature. Cardiovasc Hematol Disord Drug Targets 2018; 19:253-258. [PMID: 30516116 DOI: 10.2174/1871529x19666181205100705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/12/2018] [Accepted: 11/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Carfilzomib, a proteasome inhibitor, known as a therapeutical option for people who have already received one or more previous treatments for multiple myeloma, has well known cardiac and systemic adverse effects. OBJECTIVE There is evidence supporting that adverse effects are dose dependent, yet there is no known patient phenotype characterized by worse associated consequences, nor are there widely accepted monitoring protocols. RESULTS In this article we describe two patients with cardiovascular adverse events related to carfilzomib treatment and their clinical course. Our goal was to present two cases of daily practice, which highlighted the complexity of their management and led to underline how baseline evaluation and close follow-up with echocardiography and cardiac biomarkers, including natriuretic peptides, remain an important tool for the cardiotoxicity surveillance. CONCLUSION These reflections should lead to further studies in order to identify high risk patients for cardiovascular adverse event and clarify the real incidence of cardiotoxicity of this drug and adequate follow-up timing. Finally further research is needed to evaluate strategies for prevention and attenuation of cardiovascular complications of cancer therapy.
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Affiliation(s)
- W Serra
- Cardiology Unit, Department of Surgery, University of Parma, Parma, Italy
| | - A Fantin
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - C Longo
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - G Rabia
- Cardiology Unit, Department of Surgery, University of Parma, Parma, Italy
| | - F De Rosa
- Cardiology Unit, Department of Surgery, University of Parma, Parma, Italy
| | - C Plenteda
- Emathologic Department, University of Parma, Parma, Italy
| | - F Re
- Emathologic Department, University of Parma, Parma, Italy
| | - E Crisafulli
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - A Chetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Progressive Elevation of NT-ProBNP During Chemotherapy Is Related to Asymptomatic Cardiovascular Events in Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:167-176.e1. [PMID: 30581158 DOI: 10.1016/j.clml.2018.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/13/2018] [Accepted: 11/02/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with multiple myeloma (MM) are at risk of cardiovascular events (CVEs) as a result of disease burden- and treatment-related risk factors. Cardiac biomarkers have been reported to be more sensitive than left ventricular ejection fraction in detecting CVEs. We sought to explore CVEs risk factors in MM patients and to establish sensitive predictors of biomarkers. PATIENTS AND METHODS We studied 116 newly diagnosed MM patients who received chemotherapy in our department. Echocardiograms were examined at baseline and after 4 cycles of treatment, as well as upon clinical suspicion of a cardiac event or after an adjustment of treatment regimens. Cardiac biomarkers, including troponin T, myohemoglobin, and N terminal pro B-type natriuretic peptide (NT-proBNP), were estimated before each cycle and within 24 hours after chemotherapy, which was provided for at least 4 cycles. RESULTS Thirteen patients (11.2%) experienced CVEs, seven of which were subclinical. There was no significant difference between the CVE group and the non-CVE group in terms of general patient characteristics, MM disease factors, or chemotherapy drugs. The baseline levels of left ventricular ejection fraction and NT-proBNP were comparable between the 2 groups. NT-proBNP levels increased rapidly after chemotherapy and fell to normal levels before administration of the next cycle in all patients (60 pg/mL vs. 446 pg/mL, P < .001). Patients with asymptomatic CVEs showed a significantly higher proportion of progressively elevated NT-proBNP compared to symptomatic CVE and non-CVE patients (57% vs. 0 vs. 6.1%, P = .035). CONCLUSION The dynamic change in NT-proBNP may predict early asymptomatic cardiac damage and allow interventional strategies to avoid cardiac decompensation.
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Bringhen S, Milan A, Ferri C, Wäsch R, Gay F, Larocca A, Salvini M, Terpos E, Goldschmidt H, Cavo M, Petrucci MT, Ludwig H, Auner HW, Caers J, Gramatzki M, Boccadoro M, Einsele H, Sonneveld P, Engelhardt M. Cardiovascular adverse events in modern myeloma therapy - Incidence and risks. A review from the European Myeloma Network (EMN) and Italian Society of Arterial Hypertension (SIIA). Haematologica 2018; 103:1422-1432. [PMID: 30049825 PMCID: PMC6119131 DOI: 10.3324/haematol.2018.191288] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/05/2018] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular disease in patients with multiple myeloma may derive from factors unrelated to the disease (age, diabetes, dyslipidemia, obesity, prior cardiovascular diseases), related to the disease (cardiac AL-amyloidosis, hyperviscosity, high-output failure, arteriovenous shunting, anemia, renal dysfunction) and/or related to anti-myeloma treatment (anthracyclines, corticosteroids, alkylating agents, immunomodulatory drugs, proteasome inhibitors). Good knowledge of cardiovascular events, effective dose reductions, prevention and management of early and late cardiovascular side effects of chemotherapeutic agents are essential in current clinical practice. Myeloma experts are obliged to carefully balance the efficacy and toxicity of drugs for each individual patient. This review summarizes current data and novel insights into cardiovascular adverse events of today’s anti-myeloma treatment, focusing on carfilzomib, as a starting point for developing consensus recommendations on preventing and managing cardiovascular side effects in patients with multiple myeloma.
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Affiliation(s)
- Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Alberto Milan
- Department of Medical Sciences, Internal Medicine and Hypertension Division, University of Torino, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Italy; Rete Oncologica Piemontese, Italy
| | - Claudio Ferri
- University of L'Aquila, MeSVA Department, San Salvatore Hospital, Division of Internal Medicine & Nephrology, Coppito, Italy
| | - Ralph Wäsch
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Greece
| | - Hartmut Goldschmidt
- Medizinische Klinik, Abteilung Innere Medizin V, Universitätsklinikum Heidelberg und National Centrum für Tumorerkrankungen (NCT), Heidelberg, Germany
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology and Medical Oncology, University of Bologna, Italy
| | - Maria Teresa Petrucci
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Heinz Ludwig
- 1. Medical Department and Oncology, Wilhelminenspital Wien, Austria
| | | | - Jo Caers
- Department of Hematology, Domaine University, Liege, Belgium
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Germany
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Würzburg, Germany
| | | | - Monika Engelhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, Faculty of Medicine, University of Freiburg, Germany
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Waxman AJ, Clasen S, Hwang WT, Garfall A, Vogl DT, Carver J, O'Quinn R, Cohen AD, Stadtmauer EA, Ky B, Weiss BM. Carfilzomib-Associated Cardiovascular Adverse Events: A Systematic Review and Meta-analysis. JAMA Oncol 2018; 4:e174519. [PMID: 29285538 DOI: 10.1001/jamaoncol.2017.4519] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Cardiovascular adverse events (CVAE) with carfilzomib in patients with multiple myeloma can be potentially life-threatening and remain incompletely characterized. We performed the first systematic review and meta-analysis of carfilzomib-associated CVAE. Objective To determine the incidence of carfilzomib-associated CVAE and to compare the rates of carfilzomib CVAE among different doses and companion therapies. Data Sources PubMed, EMBASE, Web of Science, and clinicaltrials.gov were queried for the keywords "carfilzomib," "Kyprolis," and "PX-171" through January 1, 2017. Study Selection Phase 1 to 3 prospective clinical trials of carfilzomib in patients with multiple myeloma with evaluable toxic effects data were eligible for meta-analysis. Data Extraction and Synthesis Data were independently extracted by 2 reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Pooled incidence rates and relative risks (for randomized trials) and 95% confidence intervals were calculated using a random effects model. Subgroup analyses were performed to assess study-level characteristics associated with CVAE. Main Outcomes and Measures Cardiovascular adverse events were defined as heart failure, hypertension, ischemia, and arrhythmia. All-grade and grades 3 or higher AEs and study characteristics were recorded. Results A total of 514 studies were assessed for eligibility. Of those, 24 studies were eligible, including a total of 2594 patients with multiple myeloma. All-grade and grades 3 and higher CVAE were seen in 617 (18.1%) and 274 (8.2%), respectively. Phase 2 or 3 studies and carfilzomib doses of 45 mg/m2 or higher were associated with high-grade CVAE. Median age older than 65 years, prior myeloma therapies, and concurrent myeloma therapies were not associated with CVAE. For the 3 randomized clinical trials, the summary relative risk of all-grade and grade 3 or higher CVAE for patients receiving carfilzomib compared with noncarfilzomib-receiving control patients were 1.8 and 2.2, respectively. Conclusions and Relevance Carfilzomib was associated with a significant incidence of CVAE, with higher rates seen with higher doses of carfilzomib. Phase 1 studies may be underdetecting CVAE. Future studies are needed to identify patients at high risk for CVAE, develop optimal monitoring strategies, and explore strategies to mitigate these risks.
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Affiliation(s)
- Adam J Waxman
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Suparna Clasen
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Alfred Garfall
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Dan T Vogl
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Joseph Carver
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Rupal O'Quinn
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Adam D Cohen
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Edward A Stadtmauer
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Bonnie Ky
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Brendan M Weiss
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
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Lee DH, Fradley MG. Cardiovascular Complications of Multiple Myeloma Treatment: Evaluation, Management, and Prevention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:19. [DOI: 10.1007/s11936-018-0618-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Cutaneous Plasmacytoma: A Rare Complication of Multiple Myeloma and Permanent Pacemaker Insertion. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mancuso S, Carlisi M, Sarocchi M, Napolitano M, Siragusa S. Cardio-oncology in multiple myeloma: is it time for a specific focus? Leuk Lymphoma 2017; 59:1764-1766. [PMID: 29087234 DOI: 10.1080/10428194.2017.1393674] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Salvatrice Mancuso
- a Department of Oncology, Haematology Unit , University of Palermo School of Medicine , Palermo , Italy
| | - Melania Carlisi
- a Department of Oncology, Haematology Unit , University of Palermo School of Medicine , Palermo , Italy
| | - Matteo Sarocchi
- b Department of Internal Medicine and Cardionephrology , University of Genova , Genoa , Italy
| | - Mariasanta Napolitano
- a Department of Oncology, Haematology Unit , University of Palermo School of Medicine , Palermo , Italy
| | - Sergio Siragusa
- a Department of Oncology, Haematology Unit , University of Palermo School of Medicine , Palermo , Italy
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Jakubowiak AJ, DeCara JM, Mezzi K. Cardiovascular events during carfilzomib therapy for relapsed myeloma: practical management aspects from two case studies. ACTA ACUST UNITED AC 2017; 22:585-591. [PMID: 28545322 DOI: 10.1080/10245332.2017.1328165] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objectives and importance: Patients with multiple myeloma (MM) have an increased risk of cardiovascular comorbidities due to disease burden and treatment-related risk factors. Proteasome inhibitors, including bortezomib and carfilzomib, are effective and generally well tolerated anti-MM agents. However, cardiovascular-related toxicities have been reported with this class of agents, the mechanisms of which are not fully understood. We discuss the practical management of cardiovascular events during carfilzomib therapy for relapsed MM. CLINICAL PRESENTATION We present two adapted cases of treatment-emergent cardiovascular events in patients receiving an approved regimen of carfilzomib for the treatment of relapsed MM. These cases are reflective of clinical practice at the University of Chicago Medicine. INTERVENTION Using the two adapted cases, we discuss and illustrate practical approaches for management of cardiovascular events during carfilzomib therapy, including baseline cardiac risk assessment, hydration, cardiovascular monitoring, and interventions for patients with suspected cardiovascular signs or symptoms, and patient education. CONCLUSION Carfilzomib has a favorable benefit-risk profile in MM; adopting proactive practices can assist in the prevention, early detection, and management of carfilzomib-associated cardiovascular events, which may allow for continuation of therapy with this effective agent.
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Affiliation(s)
- Andrzej J Jakubowiak
- a Department of Medicine , The University of Chicago Medicine , Chicago , IL , USA
| | - Jeanne M DeCara
- b Department of Cardio-Oncology , The University of Chicago Medicine , Chicago , IL , USA
| | - Khalid Mezzi
- c Department of Clinical Development , Amgen Inc., One Amgen Center Drive , Thousand Oaks , CA , USA
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