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Myeloma

About

What is covered

This interactive flowchart covers diagnosing and managing myeloma (including smouldering myeloma and primary plasma cell leukaemia) in people aged 16 and over.

Updates

Updates to this interactive flowchart

18 July 2017
10 January 2017 Pomalidomide for multiple myeloma previously treated with lenalidomide and bortezomib (NICE technology appraisal guidance 427) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing myeloma, and preventing and managing its complications in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing myeloma (including smouldering myeloma and primary plasma cell leukaemia) in people aged 16 and over.

Updates

Updates to this interactive flowchart

18 July 2017
10 January 2017 Pomalidomide for multiple myeloma previously treated with lenalidomide and bortezomib (NICE technology appraisal guidance 427) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Myeloma: diagnosis and management (2016) NICE guideline NG35
Carfilzomib for previously treated multiple myeloma (2017) NICE technology appraisal guidance 457
Bortezomib monotherapy for relapsed multiple myeloma (2007) NICE technology appraisal guidance 129

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

NICE is unable to make a recommendation about the use in the NHS of daratumumab with lenalidomide and dexamethasone for treating relapsed or refractory multiple myeloma because no evidence submission was received from Janssen-Cilag. The company has confirmed that it does not intend to make a submission.
The NICE technology appraisal of elotuzumab for previously treated multiple myeloma was terminated because no evidence submission was received from Bristol–Myers Squibb for the technology. Therefore NICE was unable to make a recommendation about the use in the NHS of elotuzumab for previously treated multiple myeloma, but will review this decision if the company decides to make a submission.
The following recommendations are from NICE technology appraisal guidance on lenalidomide for the treatment of multiple myeloma in people who have received at least one prior therapy.
Lenalidomide in combination with dexamethasone is recommended, within its licensed indication, as an option for the treatment of multiple myeloma only in people who have received two or more prior therapies, with the following condition:
  • The drug cost of lenalidomide (excluding any related costs) for people who remain on treatment for more than 26 cycles (each of 28 days; normally a period of 2 years) will be met by the manufacturer.
People currently receiving lenalidomide for the treatment of multiple myeloma, but who have not received two or more prior therapies, should have the option to continue therapy until they and their clinicians consider it appropriate to stop.
NICE has written information for the public explaining its guidance on lenalidomide.
The following recommendations are from NICE technology appraisal guidance on panobinostat for treating multiple myeloma after at least 2 previous treatments.
Panobinostat in combination with bortezomib and dexamethasone is recommended, within its marketing authorisation, as an option for treating multiple myeloma, that is, for 'adult patients with relapsed and/or refractory multiple myeloma who have received at least 2 prior regimens including bortezomib and an immunomodulatory agent' when the company provides panobinostat with the discount agreed in the patient access scheme.
NICE has written information for the public explaining its guidance on panobinostat.
The following recommendations are from NICE technology appraisal guidance on pomalidomide for multiple myeloma previously treated with lenalidomide and bortezomib.
Pomalidomide, in combination with low-dose dexamethasone, is recommended as an option for treating multiple myeloma in adults at third or subsequent relapse; that is, after 3 previous treatments including both lenalidomide and bortezomib, only when the company provides pomalidomide with the discount agreed in the patient access scheme.
This guidance is not intended to affect the position of patients whose treatment with pomalidomide was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.
NICE has written information for the public explaining its guidance on pomalidomide.
The following recommendations are from NICE technology appraisal guidance on carfilzomib for previously treated multiple myeloma.
Carfilzomib in combination with dexamethasone is recommended as an option for treating multiple myeloma in adults, only if:
  • they have had only 1 previous therapy, which did not include bortezomib and
  • the company provides carfilzomib with the discount agreed in the patient access scheme.
These recommendations are not intended to affect treatment with carfilzomib that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
NICE has written information for the public explaining its guidance on carfilzomib.

Glossary

fluorodeoxyglucose positron emission tomography CT
fluorescence in-situ hybridisation
graft-versus-host disease
human leukocyte antigen
international normalised ratio
international Staging System
low molecular weight heparin
multidisciplinary team
multidisciplinary teams
monoclonal gammopathy of undetermined significance
asymptomatic myeloma which has no evidence of myeloma-related organ or tissue injury or a myeloma defining event

Paths in this pathway

Pathway created: February 2016 Last updated: July 2017

© NICE 2017

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