What are some recommended prophylactic medications?

What are some recommended prophylactic medications? Why are they recommended? So there are standard prophylactic medications that we give myeloma patients who are newly diagnosed or relapse refractory patients. So one important medication to give is a prophylaxis for varicella zoster or shingles infection which actually increases the incidence of shingles related to especially the proteasome inhibitors which are you know botasomib, carfilzomib or exasomib as well as the newer medication that Atomumab has been shown to increase the risk as well. So any patients that is getting any of those medications we definitely like to give them a shingles prophylaxis and acyclovir or Valdrex you know both are similarly effective so definitely We have seen you know patients do very well and have very little outbreak of shingles once they are getting those vaccines. The second group is the patients who are post an autologous stem cell transplant. Also there we see a higher incidence of shingles even though they may not be getting any treatment. So in those patients definitely it's recommended by the transplant groups to take acyclovir or Valdrex for at least a year post transplant and in some patients you know we extend that longer as well. So it is important to use definitely some sort of prophylaxis for myeloma patients. So acyclovir is an antiviral drug that is commonly used to not just treat herpes infections or shingles infection but also prevents reactivation of herpes viruses or prevents a shingles infection. So we use acyclovir as a preventative measurement to reduce the risk for our patients to have herpes reactivation or a new shingles infection. There's some drugs that we use for patients with multiple myeloma called proteasome inhibitors such as botasomep, cathilsomep or exasomep that further increase the risk for our patients to get a shingles infection or have a herpes reactivation and acyclovir is an important tool to further reduce the risk of having problems with these viruses. So the common prophylactic dose for acyclovir in patients who get a common immunotherapy with proteasome inhibitors is 400 mg twice a day as a tablet. After high dose chemotherapy and autologous stem cell transplantation we usually use a higher dose, 800 mg per mouth twice a day for a period of one year after transplant to prevent shingles infections or herpes reactivation. Is there another drug that is used instead of acyclovir? Valla-cyclovir is a very similar drug. It's a prodrag of acyclovir and can be used in almost equivalent fashion as acyclovir. Do patients who receive a vaccine for shingles need to take prophylactic medication? Even if patients who have received a vaccine for shingles, given that these patients are the vaccine efficacy is not as high as patients who don't have a cancer. So even in those patients we do recommend to take either acyclovir or Valla-cyclovir. Should newly diagnosed myeloma patients be prescribed a prophylactic antibiotic? Which patients and which antibiotic? We commonly or routinely give prophylactic medications to our patients with plasma cell diseases. This medication we commonly use is called levofloxacin. It's an antibiotic that's shown in studies to be able to prevent infections or severe infections for patients who get induction therapy for plasma cell diseases. So we recommend to use this antibiotic prophylaxis to prevent bacterial infections for patients with multiple myeloma during the first three months of treatment because that's been shown to reduce severe infections for our patients. Definitely some patients in our practice who are starting myeloma therapy or who are getting myeloma therapy do need prophylaxis for bacterial infections in addition to the prophylaxis for shingles given that there have been multiple reports now that show there is an increased risk of bacterial infections in patients as they are starting therapy or who have relapsed disease. And certain patients are at particularly high risk for that, especially the frail and the elderly patients. So in our practice, especially patients who are starting multi-agent chemotherapy or triplet or quadruplet therapy and those who are at higher risk of getting a bacterial infection, we do recommend either prophylactic Bactrim, which is both a good prophylaxis for bacterial infection as well as a particular type of pneumonia called a PCP pneumonia. There have been studies around this as well and there was a large trial done in Europe comparing patients who got a prophylactic antibiotic called Lavaquin. It included all patients who were starting new therapy for multiple myeloma and it did reduce the incidence of infections, although there was not much of a mortality benefit. So in our practice, we don't give a prophylactic antibacterial to everyone, but to a particular groups of patients, especially those who had infection before and especially who are frail and elderly, who can get sick from infections very quickly. So typically a younger patient, we don't think we really need to give universal antibacterial prophylactic. We are aware that I learned it from Mert when I was there. They used levofloxacin as prophylactic antibiotic and there is also a phase three study published by Draisen where he used levofloxacin and the patients had fewer infections and better outcome. So of course it is important. We have tried to study the use of cladromycin in patients in a prospective small study and we had to stop the study prematurely simply because of the side effects of cladromycin. And these patients, they had severe abdominal pain. They also had enterocolitis and more sepsis than the other patients. So you have to be very careful what you do. Furthermore, we learned from this study that probably it also gave more side effects to botesomib simply because of the interaction with the sepsis enzymes. So then back again, very careful examination of when you want to do antibiotics and be careful with resistant bacteria. So Bactrim is a drug that is used for a prophylactic specific type of atypical pneumonia called PJP pneumonia that is very common in immunocompromised patients. We sometimes use this drug for patients with plasma cell diseases, particularly when they receive high dose chemotherapy or after they receive high dose chemotherapy, but also sometimes for patients who get more than usual aggressive therapy for multiple myeloma or regimens that contain high doses of steroids or patients who receive multi-chemotherapy, multi-agent chemotherapy. Do high doses of dexamethasone lower your immune system? We have gone from using dexamethasone for four days to typically now only weekly. And many of our elderly patients actually don't get even the 40 milligram and we try to lower the dose because dexamethasone actually is a toxic drug. So as somebody who is getting a higher dose of dexamethasone and is again in one of those high risk groups, we tend to have a low threshold for starting those prophylaxis. A lot of our younger patients also get high dose dexamethasone, but we don't typically give it to everybody. So it goes by case to case basis. Are Aspen prophylactics used? So that's another area that's important as a prophylactics. So we have known now for about 20 years, especially when we started using immunomodulators, the first one was thalidomide, then lenalidomide, that patients who are starting therapy with these drugs and especially are in the early stages of therapy tend to have a particularly high risk of getting a blood clot. And that risk has varied anywhere from 8 to 10 percent in some studies going up to even 40 to 50 percent incidence of getting a blood clot. So there have been multiple trials that have looked at using medications to prophylactics. And typically every patient who gets any of these drugs, immunomodulators, we do recommend taking a prophylactic medication. For patients who are low risk for a blood clot, younger patients who are walking around and have no mobility problems and no history of blood clots, aspirin is considered a good enough prophylaxis. But for patients who are high risk, let's say somebody who has a bone fracture, is bed bound or elderly who is not very mobile but are newly diagnosed and starting one of these medications, we do recommend something more than aspirin and that could include a prophylactic dose of a drug called lovinox, which is a blood thinner, or a low dose of coumadin. And sometimes even the newer drugs called the DoAX, we have been using those in our practice as well. So it again goes by case to case basis. Somebody who is getting one of these drugs should get some prophylaxis and then it depends on what you are going to use, it depends on the risk of the clot. When is aspirin used? So aspirin is an antiplatelet agent that we know is used to prevent platelets from forming blood clots. And so we use a psychovir primarily in patients who receive treatment with so-called IMIDs such as thalidomide, linalidomide or pomalidomide. So we know that patients who receive these medications have an increased risk for blood clotting and to minimize the risk for blood clots, we concurrently prescribe aspirin as an antiplatelet agent in a dose of 81 milligrams a day. What other prophylactics are there? So the third thing that is important is actually bony prophylaxis. So as we know, myeloma is a disease that affects the bones and about 70 to 80 percent of patients actually have bone disease to begin with. And that bone disease puts at a risk of increased fractures that can lead to significant morbidity including pain and sometimes limited the patient's activity level. So it's very important to give every patient with multiple myeloma some bony prophylaxis. And currently there is a lot of data and a lot of studies have been done with a group of drugs called bisphosphonates. And the commonly used drug is a drug called Zometa or zoledronic acid that has been studied now for close to about 15, 20 years and has consistently shown in multiple studies that the incidence of bone fractures reduces the incidence of complications related to bone fractures. In some studies it was also improved the myeloma outcomes including the relapse rate as well as survival. All those remain controversial but there is no controversy out there that it does improve a bone health in a significant way. So there are a group of patients who have kidney disease who are not really a good candidate for Zometa because it can have a bad effect on the kidney in those patients. And there was a new drug that was approved now almost five years ago called Dinosumab or other name is XGBA which is actually an antibody drug which does not have any bad effect in patients who have kidney disease. So in patients who have low kidney function we use that drug instead of Zometa and they are both similar in efficacy in terms of improving the bone health. Individuals diagnosed with myeloma should have a discussion about the following prophylactic medications with their healthcare team. Medications to prevent shingles especially when prescribed a proteasome inhibitor or anti CD38 monoclonal antibody are recommended. Antibacterial medications may be prescribed for select populations who are high risk for infection. Blood thinners are used for individuals who are taking IMIDs and bone strengtheners are used for two years after diagnosis to prevent myeloma bone disease from occurring.