Chief Complaint:

Fatigue and leg swelling

History of Present Illness:

Martin returns to his hematologist for a routine follow-up visit complaining of increasing lethargy and fatigue, achiness, nausea, constipation and swelling of his legs. Subsequent to a diagnosis of multiple myeloma 8 months prior, he received induction therapy with thalidomide plus dexamethasone (Thal/Dex), and then underwent successful autologous stem cell transplantation (ASCT). He achieved a Very Good Partial Response (VGPR) and has since continued therapy with thalidomide/dexamethasone with routine monitoring at three-month intervals. 

Although prophylactic warfarin was initiated with induction therapy, Martin has had difficulty regulating his INR. Between visits, he has also become increasingly fatigued, especially when faced with routine chores around the house. Other complaints include a decreased appetite and mild nausea throughout the day, urinary frequency (7-8 times daily), and leg swelling during the past week, more so on the right. He attributes an ongoing achiness in his shoulders, lower back and legs, all independent of physical activity, to a viral syndrome.

Accreditation Statement:

MedCases, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. 

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education.

Policy on Speaker and Provider Disclosure:

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of MedCases to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The presenting faculty reported the following. 

Kenneth C. Anderson, MD	Consultant and Grant/Research Support: Celgene Corporation, Millennium Pharmaceuticals, Novartis Pharmaceuticals
Ruben Niesvizky, MD	Speakers Bureau: Celgene Corporation, Millennium Pharmaceuticals, Novartis Pharmaceuticals, Ortho Biotech  Grant/Research Support: Celgene Corporation, Millennium Pharmaceuticals  Consultant: Millennium Pharmaceuticals
Steven T. Rosen, MD, FACP	Consultant: Abbott Laboratories, Allos Therapeutics, Berlex Laboratories, Biocryst Pharmaceuticals, Celgene Corporation, Cell Therapeutics Inc, Genentech Inc, Genta, Ligand Pharmaceuticals, Eli Lilly and Co, Pharmion Corporation, Sigma-Tau Pharmaceuticals, SuperGen, Therakos Inc, Wyeth
G. David Roodman, MD, PhD	Consultant: Acceleron Pharma, Amgen Inc, Celgene Corporation  Consultant, Speakers’ Bureau, Grant/Research Support: Novartis Pharmaceuticals
Planning Committee Members
Dorothy Schirf, MD	Stockholder: Alkermes, Inc, Ligand Pharmaceuticals, Northfield Laboratories, Inc, Pfizer, Inc

Harvey Mossman, MD; Carolyn Darrow, MPH; and Sharon Barnett have indicated that they have not received financial support for consultation, research, or, evaluation, or have a financial interest relevant to this online activity. 

Method of Participation:

This Internet-based activity takes approximately 2 hours to complete. You should review the important information on this page, check the box below and click the button to proceed to the case. First-time visitors will be asked to complete their profile. After completing the activity you will answer a multiple-choice post-test and complete an evaluation form online. Once completed, you will be able to save your certificate to your own computer and print it on your own printer.

Statement of Responsibility:

MedCases takes responsibility for the content, quality, and scientific integrity of this CME activity.

Course Director and Principal Faculty:

Kenneth C. Anderson, MD (CO-CHAIR)
Kraft Family Professor of Medicine
Harvard Medical School
Chief, Division of Hematologic Neoplasia
Director, Jerome Lipper Multiple Myeloma Center
Dana-Farber Cancer Institute
Boston, MA

Ruben Niesvizky, MD (CO-CHAIR)
Director, Multiple Myeloma Program
Center of Excellence for Lymphoma and Myeloma
New York Presbyterian Hospital – Cornell University
New York, NY

Steven T. Rosen, MD, FACP
Genevieve Teuton Professor of Medicine
Feinberg School of Medicine
Director
Robert H. Lurie Comprehensive Cancer Center
Northwestern University
Chicago, IL

G. David Roodman, MD, PhD
Professor of Medicine
Vice Chair for Research
Director, Myeloma Program at UPMC
University of Pittsburgh
Pittsburgh, PA

Target Audience:

This activity is intended for hematologists and community oncologists.

Prerequisites:

There are no prerequisites

Statement of Need:

Significant progress has been made in diagnosis, assessment, and treatment of patients with multiple myeloma. The utilization of new classes of therapy, as well as improved strategies for managing toxicities of these medications, have resulted in new and more effective options that can prolong disease control and survival. Clinicians are now able to change the traditional goals to a more ambitious objective of achieving a complete response, in the hopes of longer progression-free survival and improved quality of life for their patients. Further, the need for stem cell transplants and the potential for associated medical complications may continue to diminish based on the potential for achieving complete remissions with combination therapy in newer protocols. 

However, healthcare practitioners are faced with overcoming several clinical barriers quickly to achieve optimal outcomes in their patients. The rapidity of change in this continually evolving arena may cause delays incorporating newer evidence into clinical practice. Lack of familiarity with the newer protocols and the mechanisms of action of newer agents, the potential for adverse effects, and concerns about management of toxicities are all important obstacles in updating the clinical paradigms. Overcoming these obstacles will enable physicians to apply updated guidelines and current evidence to improve the quality of care for multiple myeloma patients.

Objectives:

On completing this activity, you should be able to:

• Execute diagnostic and monitoring protocols appropriate for progressive myeloma
• Implement standard therapy of progressive myeloma in the context of common comorbidities
• Successfully manage major therapeutic toxicities of myeloma patients                                                        

Off-label Statement/Unapproved Uses:

In accordance with US Food and Drug Administration (FDA) requirements regarding the disclosure of off-label, investigational, or unapproved recommendations for the use of drugs or devices, the audience is advised that content in this activity does not contain reference(s) to uses of drugs or devices that are off-label, investigational, or unapproved in the United States. The following information is provided for educational purposes and not to endorse off-label use. 

No faculty member has indicated that their presentation will include information on off-label products.

Disclaimer:

The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of MedCases’ name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients. 

All information contained within this activity is intended for educational purposes only. Physicians and other health care professionals are encouraged to consult other sources and confirm the information contained in this site because no single reference or service can take the place of medical training, education and experience. Consumers are cautioned that this site is not intended to provide medical advice about any specific medical condition they may have or treatment they may need and they are encouraged to call or see their physician or other health care provider promptly with any health related questions they may have. 

The MedCases Web site does not define a standard of care, nor is it intended to dictate an exclusive course of management. Cases are provided for informational and educational purposes only and are not intended as medical advice. This information should not substitute for a visit or consultation with a health care provider.

Privacy and Confidentiality:

MedCases is committed to maintaining site visitor's rights to privacy and confidentiality of personal information. Personal information about site visitors and specific visitor's access and navigation, and information volunteered by site visitors, such as survey information and site registration information, may be used by MedCases to improve the site but will not be shared with or sold to other organizations for commercial purposes without the site visitor's express permission. Please click here to read MedCases' detailed privacy policy and other terms of using this web site.

Copyright Statement:

© 2009 MedCases, LLC.

For Further Information:

MedCases 
4365 US Highway 1, Suite 207 
Princeton, NJ 08540 
Phone (609) 454-0680 
Fax (609) 951-0112 
cme@medcases.com

Hardware/Software Requirements and Technical Assistance:

This Internet-based CME activity is best experienced using a current generation browser such as Internet Explorer 5.5 or higher. This web site requires that JavaScript and session cookies be enabled. In addition, you will require the Adobe Flash Player plugin, in order to view the on-line case study.

Detailed Requirements:

• 128 Mb RAM
• Windows 98 or newer
• Adobe Flash Player 8 minimum needed.
• Audio playback with speakers for programs that have video content
• Internet Explorer 5.5 or higher or Mozilla Firefox 1.0 or higher
• 1024 x 768 resolution
• Broadband connection highly recommended                                                             

More information about the software described above is available by following the links below: 

• Free Adobe Flash Player plugin 
• Free Adobe Acrobat Reader                                                              

If you need assistance, please use the Contact Us link below and contact the appropriate address.