Case Studies: Inpatient vs Outpatient Treatment and Management

Beth Faiman

Melanie, in our first couple of conversations we discussed some newly diagnosed patients and supportive care considerations. Today I thought it would be nice to have some case studies to go over. Your perspective is so great because it's mostly inpatient and mine is mostly outpatient. So, I'd love to share with our audience how these are two different but complementary roles.

Melanie Douglas

Absolutely. This is just a great dialogue, and it's excellent to discuss the subtleties. This really gets across the whole continuum of the patient's care because a lot of these patients come in and have to be managed inpatient initially when they're symptomatic with electrolyte disturbances, bone marrow failure, or lytic lesions that might inhibit their full quality of life. Once they're stabilized, we can then transition them to the outpatient setting.

Beth Faiman

That makes sense. Let's talk about a typical case presentation of somebody that you've had in the hospital, and then maybe we can go over some of the considerations in inpatient and then what I might do in outpatient and how we would follow that patient's continuum.

Melanie Douglas

Sounds good. I had a patient come in, 59 years old, fit, active, newly diagnosed standard risk, IgA lambda multiple myeloma. He had a very symptomatic lesion of the left iliac wing. He needed radiation because he couldn't function, he couldn't even walk. He needed a PCA in the hospital, so he had to be admitted to the hospital for pain control. We got that under control with the PCA, transitioned that to oral opiates, and then we started radiation on the inpatient side as well. Then we were able to give him a dose of CyBorD because he was symptomatic with the CRAB criteria. He had a mild AKI and hypercalcemia. We had to treat with fluids. Then we also gave CyBorD and he did very well. He transitioned to a four-drug regimen, daratumumab, lenalidomide, bortezomib, and dexamethasone, once he was an outpatient, and his labs and symptoms are now more under control.

Beth Faiman

Excellent. One of the things I think of when people are admitted with osteolytic lesions of the weight-bearing bones, such as femur or pelvis, is not only the pain control, but what about the stability? We oftentimes will consult with orthopedics just in case they need surgical stabilization.

Melanie Douglas

Absolutely. We did consult orthopedics on this case as well. They put in weight-bearing recommendations. They didn't want him to bear his full weight on his left leg, but luckily they thought that he didn't need surgery, and radiation did the job. He had multiple fractions of radiation as an inpatient to help.

Beth Faiman

Then that's a very important point. I think a lot of times we forget to discuss the important role of radiation in myeloma. We're often focused on treatment and surgery.

Melanie Douglas

Yes, exactly.

Beth Faiman

Patients such as your case example who present with a large osteolytic lesion in the left iliac wing, spine, or other site may have a diagnosis of a solitary plasmacytoma. In these patients, only local treatment with radiation and/or surgery is recommended. To determine if a patient presents with a solitary plasmacytoma, you must do the entire workup to ensure the patient had no other sites of disease. This would include a whole-body PET-CT scan to rule out osteolytic lesions, as well as serum and urine testing to assess for an M protein and ensure the bone marrow biopsy has no evidence of clonal plasma cells. The incidence of solitary plasmacytoma¹ is lower than myeloma but could be considered in this case.

Melanie Douglas

That's a really good point, Beth, because absolutely, we did a bone marrow biopsy as inpatient to help us see what the appropriate management was. We did realize that we needed to have a bigger discussion with our radiology/oncology colleagues on what to do and how to time everything because we also wanted to give him chemo as well.

Beth Faiman

Absolutely. And sometimes we see people admitted to the hospital who have large osteolytic lesions. You have to consider future options and weigh the risks of bone marrow or organ toxicity in patients who undergo radiation, with the benefits of disease control. High doses of local radiation to areas such as the sternum and the pelvis can cause future bone marrow problems. We recently had a case of somebody who was admitted with this large sternal mass, but no evidence of disease elsewhere in the blood or the urine. We did a whole-body PET scan and there were no FDG-avid lesions anywhere. A whole-spine MRI did not show any lytic lesions or hypermetabolic disease, and the bone marrow was clear. But there was this sternal mass, so we provided a lower dose of radiation, just enough, working with radiation oncology colleagues, so that the patient didn't need any systemic chemotherapy. This individual will be closely monitored with serum and urine studies, as well as intermittent bone imaging, to ensure they don’t progress to multiple myeloma over time.

So you treated your patient with CyBorD, and he was discharged. What were your other supportive care considerations, such as antiviral agents or antibiotics?

Melanie Douglas

We discharged him on an antiviral agent. There's always a risk of herpes zoster reactivation, so we discharged him on acyclovir. We also discharged him on pantoprazole because a side effect of steroids can be acid reflux. Of course, he watched his sugars. We told him about the possible side effects of insomnia and hypertension. So we were looking at and monitoring all these things as well.

Beth Faiman

Those are great key points. The other thing I think we forget about in our newly diagnosed myeloma patients is the importance of immunization. We know that there's an increased risk of pneumonia with many of our monoclonal antibodies, particularly CD38 monoclonal antibodies such as daratumumab and isatuximab. We really want to make sure that those patients have received the pneumococcal vaccination and the seasonal, inactivated influenza vaccination. And I still recommend that patients receive at least two COVID vaccines, although these recommendations continue to change. Melanie, do you provide COVID immunizations to your patients in the hospital?

Melanie Douglas

These days I haven't come across it. When COVID started, that was a different story, but of course we still have to coordinate that with the primary oncologist. I would hypothesize that maybe something like daratumumab or a monoclonal antibody might render the COVID vaccination less effective, since it depletes antibody B cells.  With regard to vaccination, I'd like to discuss it with the oncologist to have an appropriate timeline of when they can have the maximum efficacy from the vaccine.

Beth Faiman

Yes, absolutely. And primary care providers will vaccinate patients too, so it’s important to update the electronic medical record. 

Some of my patients who receive proteasome inhibitors or monoclonal antibodies will not want to take acyclovir or valacyclovir for shingles prevention because they received a Shingrix vaccine and feel protected against shingles reactivation. Despite this vaccine, I do recommend oral antiviral prophylaxis, as the initial studies of the Shingrix vaccine did not include immunocompromised individuals on active chemotherapy. We do still give the Shingrix vaccine after transplant and after CAR-T cellular therapy. But as far as a newly diagnosed patient who's previously received Shingrix, I still recommend antiviral prevention. Is that something you would agree with, Melanie?

Melanie Douglas

Actually, I just recently saw a patient who unfortunately was not compliant with her acyclovir, and then she had a herpes lesion reactivation. We had to give her a higher treatment dose of antiviral. So we definitely have to emphasize compliance with our patients as well. And then always keep in mind that acyclovir is renally cleared. If a lot of these patients have an acute kidney injury, we might have to reduce the dose, such as maybe 200 mg twice a day or even once a day.

Beth Faiman

That's a good point for all of our patients, to consider GFR when prescribing not only the chemotherapy, but also supportive care. Remember, you can have an 80-year-old patient with a serum creatinine of 1.1, but if they weigh 96 pounds, they can have a stage 3 chronic kidney disease, for example. So always look at the creatinine clearance or the GFR calculation, whatever you use in your hospital, because there's a functional decline in patients as they age with their GFR and renal function.

Melanie, I wanted to ask you something regarding inpatient care. I know you're focused on acute phase and getting them diagnosed and then safely out of the hospital. Do you set goals for long-term expectations? Because when there’s a diagnosis of multiple myeloma, it's treatable but not necessarily curable at all. What do you tell patients when they're newly diagnosed in the hospital?

Melanie Douglas

That’s a really good question. It’s always a balance, right? We want to provide hope, but we don't want to be unrealistic and tell them that one day they're going to be off all of these medications, so easily at least. We just tell them, "Okay, this is the reason we're giving you chemotherapy. We always do a risk benefit scenario, and we feel that your disease is treatable, so this is why we're giving you all these drugs with these different side effects and toxicities. Of course, we’ll carefully consider attributes of your myeloma such as genetic markers and blood counts, your individual medical history, as well as performance status. Most importantly, we’ll have a thorough discussion with you in regard to what the treatment would entail and potential side effects.” Quite frequently, there’s more than one treatment option for the patient, so an open dialogue between the medical team and the patient is extremely important. Beyond medical considerations, chemotherapy, radiation, or CAR T-cell or stem cell transplant planning involves reaching out to family, home health aides, and/or social workers to maximize the patient’s support system.

We have a lot of multiple myeloma patients who survive for years. Of course, it depends on the patient's profile, which is exactly what I tell them, but it's always a balance between giving them hope but also being realistic. We want them to be compliant, and I think hope plays a really vital role in maintaining their compliance so they can get better.

Beth Faiman

Yes, I agree. And as an outpatient provider, I typically set those expectations for length of therapy. We've had prior discussions in this Expert Conversations series about how so many conditions in medicine are treatable but not curable. I give examples such as diabetes and hypertension, and how once you start a medication, you can’t necessarily cure chronic conditions, but you can treat and control them. So that's what we tell our patients who are newly diagnosed with myeloma. They are on induction treatment for four to six cycles, and then after a period of remission, we can consolidate that remission with stem cell transplant. Or if they don't get a transplant, if they're not a transplant candidate, we'll go into a maintenance phase with lesser doses of those same effective drugs, which will be long term. I talk to the patient and the caregiver, I highlight resources through the Leukemia & Lymphoma Society and other organizations, and really the aim is to keep the disease under control for long term.

Melanie, thanks so much for sharing your knowledge and experience.

Melanie Douglas

I appreciated learning more about the outpatient experience from you, Beth, and it translates into a lot of what I do on the inpatient side.