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Keywords:

  • myeloma;
  • thalidomide;
  • dexamethasone

We recently reported our experience of treating nine patients who had advanced myeloma with thalidomide (Myers et al, 2000). We have now accrued data on 26 patients, with an overall response rate of 77% (with a reduction of at least 25% in paraprotein/light-chain excretion), 53% having a reduction of 50% or more. We note with interest the letter by Tiplady & Summerfield (2000) reporting the use of continuous, low-dose dexamethasone (4 mg) and showing a response rate of 6 out of 15 patients (40%) with at least a 50% reduction in paraprotein in patients with advanced myeloma.

Seven of our patients had low-dose dexamethasone added, in five cases because of a lack of a continuing response to thalidomide alone and in two cases because of a severe rash with thalidomide, which was abolished by the addition of dexamethasone. The latter was used in a similar way to that described by Tiplady & Summerfield (2000), commencing at 4 mg and reducing slowly over a few months. Five of the seven patients showed further reductions in paraprotein/light-chain excretion of 80%, 68%, 61%, 34% and 21% (the latter reduction was just 1 week after commencing dexamethasone). Two patients did not respond. The two patients with a rash had reductions of 68% and 34%. Of the other patients, most had previously been treated with pulsed dexamethasone with either no response or unacceptable side-effects.

Other authors report synergistic effects of dexamethasone and thalidomide, possibly via their effects on interleukin 6 (IL-6), other cytokines in the marrow milieu and a direct effect on myeloma cells. A recent study by Rajkumar et al (2000) reported a 77% response to the combination of 200 mg of thalidomide plus pulsed dexamethasone in newly diagnosed cases of myeloma. Side-effects were not insignificant in this study, with skin rash in 50%, sedation in 42%, constipation in 59% and neuropathy in 35%. The use of continuous low-dose dexamethasone with or without thalidomide was associated with relatively fewer side-effects in both Tiplady's study and ours (Myers et al, 2000; Tiplady & Summerfield, 2000) and should be considered as an alternative to pulsed dexamethasone plus thalidomide in cases in which the response to thalidomide alone is poor.

References

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  2. References
  • Myers, B., Crouch, D., Dolan, G. (2000) Thalidomide treatment in advanced refractory myeloma. British Journal of Haematology, 111, 986.DOI: 10.1046/j.1365-2141.2000.02393-2.x
  • Rajkumar, S.V., Hayman, S., Fonseca, R., Dispenzieri, A., Lacy, M., Geyer, S., Wellik L., Lust, J., Kyle, R., Greipp, P., Gertz, M., Witzig, T. (2000) Thalidomide plus dexamethasone and thalidomide alone as first line therapy for newly diagnosed myeloma. Blood, 96, 11168a.
  • Tiplady, C.W. & Summerfield, G.P. (2000) Continuous low-dose dexamethasone in relapsed or refractory multiple myeloma. British Journal of Haematology, 111, 381.DOI: 10.1046/j.1365-2141.2000.02372.x