BETA - What is anemia? What causes anemia in myeloma patients? How is anemia monitored? How is myeloma related anemia treated?

What is anemia? Anemia is a low hemoglobin or low red blood cells, so lower than what your baseline is and usually at least a few points lower because otherwise it could be just a one time or things but you want to consistently see it's lower, that would be anemia. Anemia can actually be from multiple causes and very much has to be individualized as to why it's happening. What are some symptoms of anemia? Symptoms of anemia can be fatigue which is more than what you would expect, sometimes hair thinning or hair loss, nails that could be easily breaking. One more symptom for anemia would be pica which is usually seen more with iron deficiency anemia where people may want to eat things like chalk or ice or things so some craving for odd item can be something you want to test for iron deficiency but mainly it's the fatigue because of low hemoglobin. What are the types of anemia? Is all anemia the same? When we think about the types of anemia you can think about nutritional deficiencies, that would be things like iron deficiency, vitamin B12 deficiency, folate deficiency and then other types could be maybe the cells are being formed but they are breaking down in the circulation, that's what we call hemolytic anemia or the lysis or breakdown of the red blood cells. That is typically not that common in myeloma but carfilzomib, one of the drugs used can sometimes lead to some hemolysis and if you notice anemia while on carfilzomib that could be something to discuss with your doctor. Other types of anemia would be lower production of red cells and that could be sometimes when the myeloma is very active or crowding out the bone marrow, there's not, with the plasma cells there's not enough space for the normal red blood cells to grow and form and that's anemia due to just lack of production and usually when patients are newly diagnosed with myeloma and present with anemia, that's the kind of anemia that they have because they're just not making enough red cells due to the bone marrow not able to keep up with making myeloma cells and red cells. This can also be seen at relapse when the myeloma gets active again and then lastly sometimes with therapies for myeloma or blood disorders being common in other blood disorders being common in myeloma, sometimes you can see myelodysplastic syndrome that could be a cause or other blood disorders that may be causing anemia. So if the anemia is not improving with looking for nutritional deficiencies or hemolysis, then it may be worth doing a bone marrow biopsy to look at what the cause might be. Another good marker in the blood called reticulocyte count is a helpful marker to understand how the function or how the bone marrow is doing in terms of red cell production. The reticulocytes are basically the baby red blood cells or the early stages and if you see high enough levels in the blood, then you know that the bone marrow is doing its job and maybe either blood is being lost or there's a hemolysis going on. But if they're not just making enough, the reticulocyte count will be low so it could be in a nutritional deficiency or related to a bone marrow process that's leading to abnormalities. I didn't mention this but anemia due to blood loss is also possible. Typically it's not directly related to myeloma but it could be due to GI bleeding or something that could be related to having low platelets or ulcer or a polyps or another malignancy or something else that leads to the bleeding. So if especially older women and men who are not having menstrual cycles have anemia where there is iron deficiency, we have to look for blood loss as well. And then lastly when you think about chemotherapy for myeloma, things like stem cell transplant or even immune therapies like CAR T cell therapy can sometimes lead to anemia for patients and usually it recovers with time but this is something again to discuss with your doctor if it's not recovering maybe we need to test and see what might be the cause. It's basically monitoring the hemoglobin levels and looking at a trend over time. It's most important to know where your baseline is. Somebody's baseline may be 14 or 16 before they were diagnosed many years ago or somebody's might be 12 and so knowing that baseline helps to understand how much or the degree of anemia. And then like I mentioned the reticulocyte count could be another marker that helps you understand the type of anemia and then there are other tests we do like a full panel for anemia would include things like the vitamin B12, the folate, the iron studies, lactate dehydrogenase and haptoglobin for hemolysis or hemolytic anemia and the Coombs test too. So this is just the comprehensive workup that's typically done if the cause is not known and then really if nothing's found on those blood tests then the bone marrow would be the next test to work up anemia. How is anemia treated and managed? For anemia because it can be so heterogeneous in its causes, the first thing is to identify what may be causing this and once that is identified then it's possible to treat that. Often a patient who have anemia assume that if they have anemia they should just eat more red meat or eat more iron rich foods and it's going to fix the anemia but that's not the case because unless it is truly related to iron deficiency eating more of those foods is not going to improve the anemia. So anemia related to myeloma would not improve from eating foods rich in iron if there's no iron deficiency to begin with. So if it's a nutritional deficiency like B12 or folate or iron then treat that. If it's a drug related like carfilzomib induced anemia or toxicity then maybe lowering the dose or stopping the drug. If it's related to the myeloma then we need to treat the myeloma to improve the anemia. If it's related to the therapies that we're giving either it will recover once we stop the therapy like in the case of a transplant which is a one time or a CAR T cell or if it's a therapy that's ongoing we may need to adjust the dose if that's something that's significant. So it really depends on what the cause is. Anemia is low red blood cells and this can come from treatment and also can come from too many plasma cells in the bone marrow and your bone marrow can't make the red blood cells like it should. It can be managed with the blood transfusion if the numbers are low enough and patients are symptomatic. It can also be managed with some hormonal growth factors so there's treatments for chemo related anemia. An example of a drug is something called Procrit or Aranasp or erythropretin stimulators. That can be given to patients too who are on treatment. Can diet have an effect on anemia? Diet can have an effect on anemia so there's a lot of different types of anemia. Iron deficiency is one type of anemia and when the anemia comes from low iron then diet can be helpful but generally speaking myeloma patients are anemic either from the disease or the treatments. There is one more type of anemia, anemia of inflammation that I didn't talk about but that's usually anemia of inflammation or chronic disease where because there's enough inflammation in the body there is a reduction in red cells because the bone marrow is not able to keep up with making it and due to the inflammation and the iron gets sequestered into the bone marrow when there's inflammation. So that kind of anemia we have to treat the underlying cause of the inflammation and sometimes maybe if there is systemic inflammation diet or foods that are less inflammatory may help but in general otherwise anemia needs to be individualized in terms of what the cause is.