Multiple MyelomaUrgent

Oncology · Ward Pathways · Free — no sign-in

CRAB: ↑Ca, Renal, Anemia, Bone lytic lesions; older adult, high total protein

Calculators:
  1. Order: SPEP/UPEP (M-spike) + free light chains
  2. Most specific: Bone marrow >10% plasma cells — or SLiM biomarkers (≥60% plasma cells, FLC ratio ≥100, >1 focal MRI lesion)
  3. Treat: Daratumumab + VRd (D-VRd quadruplet, PERSEUS) first-line → autologous transplant if eligible; transplant-ineligible → D-Rd (MAIA); BCMA bispecifics/CAR-T at relapse; bisphosphonates for bone

Order set

  • SPEP/UPEP + free light chains
  • Ca, U&E, FBC
  • Skeletal survey/MRI
  • Bone marrow biopsy
  • β2-microglobulin

Criteria

AdmitCRAB emergency (↑Ca, AKI, cord compression, hyperviscosity)
ICUHyperviscosity, severe AKI needing support
DialysisMyeloma-cast AKI with AEIOU
TransfuseSymptomatic anaemia
DischargeCRAB controlled, induction + bone protection, follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Hypercalcaemia
  • AKI
  • Cord compression
  • Hyperviscosity
Differentials
  • MGUS
  • Metastatic bone disease
  • Primary amyloid
Common mistakes
  • Missing CRAB features
  • NSAIDs/contrast worsening renal function
Disposition & follow-up

Treat CRAB; induction ± transplant; bone protection.

Discharge package
MedicationsInduction regimen (D-VRd); bisphosphonate; analgesia — type & screen BEFORE first daratumumab dose (anti-CD38 interferes with transfusion crossmatch)
Follow-upHaematology
VaccinationInfluenza, pneumococcal (infection risk)
Warning symptomsBone pain, confusion, reduced urine, infection
💊 Treatment detail — doses & preparation
Bortezomibproteasome inhibitor
Dose1.3 mg/m² SC/IV on days 1, 4, 8, 11 of 21-d cycles (myeloma)
Preparation3.5 mg vial reconstitute; SC preferred (less neuropathy)
MonitorPeripheral neuropathy, platelets, shingles prophylaxis (aciclovir)
Lenalidomideimmunomodulator
Dose25 mg OD d1–21 of 28-d cycle (myeloma, with dexamethasone); renal adjust
Preparation5–25 mg capsules
MonitorFBC (neutropenia), VTE prophylaxis mandatory, teratogenic (REMS)
Dexamethasone (myeloma)corticosteroid
Dose20–40 mg PO weekly (days 1, 8, 15, 22 of cycle)
Preparation2/4/20 mg tablets
MonitorGlucose, infection, insomnia; PPI cover
Zoledronic acidIV bisphosphonate
Dose4 mg IV over ≥15 min (hypercalcaemia, myeloma bone); renal dose-adjust (3–3.5 mg if CrCl 30–60)
Preparation4 mg/5 mL ready solution or vial dilute in 100 mL NS
MonitorCa²⁺, creatinine; hypocalcaemia/hypophosphataemia after; dental review (ONJ)
📖 IMWG MyelomaReviewed July 2026

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