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Dr. Kalaycio: That's an interesting observation that we've not made, with regard to the placement of lines. We've certainly seen clots when aspirin is interrupted whether for surgery, or because someone is stopping it for another reason.
We also use acyclovir prophylactically forever. We do not routinely replace gamma globulin for hypogammaglobulinemia. We would if there were recurrent and relatively severe infections. We don’t typically do it routinely just for low gamma globulin levels. Where do you stand on that?
Dr. Lonial: I completely agree with you. If they've had two or three recurrent infections in one season, then we'll give them intravenous immunoglobulin maybe every month, or every other month, for a couple of doses. We don't just replace the number.
Dr. Kalaycio: Right. For the young patient—under the age of 50 even—with multiple myeloma, whether high risk or low, current guidelines do not suggest the routine use of allogeneic transplant (ALLO) outside of the context of the clinical trial.2 We have conformed to that recommendation here, and I'm curious if you feel the same way at Emory.
Dr. Lonial: Yes, I do. I think in the context of a well-designed trial, it is perfectly appropriate. To me it's all about risk/benefit. I was trained as an ALLO transplanter, so I know the argument. We'll say this is your only chance at long-term cure.
That is true, if you're willing to accept a 10% long-term chance of cure. What is often underplayed is the risk of graft-versus-host disease, and the ongoing risk of relapse that continues to occur, not just one year, but two, three, four, even five years out from the ALLO transplant. I think if it's a risk that a patient is willing to take, and they're making an informed decision, I have no issues with that at all—especially if done in the context of a clinical trial. Outside of that, I think it's a pretty risky proposition.
Dr. Kalaycio: I agree.
