This is the tenth part of our series about the condition based on our patient booklet “Fast Facts for Patients: Waldenström Macroglobulinemia”. This blog posts focuses on supportive treatments for Waldenström macroglobulinemia (WM).
Supportive treatments are designed to counteract some of the symptoms of the disease and the side effects of treatment. In WM, supportive treatments include antibiotics to prevent infections (which may occur during chemotherapy cycles), blood transfusions, iron infusions, and plasmapheresis and intravenous immunoglobulin (IVIG).
Iron is crucial for many bodily processes, including the production of red blood cells. In some people with WM, iron is not used correctly in the body. This can lead to anemia, even if there is not a large number of LPL cells in the bone marrow.
Taking iron in tablet form (oral) or in the form of a drip into the vein (intravenous) may be helpful in these circumstances. Receiving iron replacement can boost the hemoglobin and improve energy levels, delaying the need to start chemotherapy. It is important that other causes of iron deficiency (such as bleeding) are excluded first, though. Intravenous iron given once or twice a week apart is generally more effective than taking iron orally.
Your blood counts can decrease as a result of the WM itself or because chemotherapy is affecting your bone marrow as a side effect. If the counts fall to levels that cause troublesome symptoms, the medical team will consider giving you red blood cell or platelet transfusions. Transfusions are given through a cannula (a thin flexible tube) into a vein; this can be done either as a day case or as an inpatient.
Having a low white blood cell count increases the risk of infection. White blood cells cannot be given by transfusion. Instead, growth factors can be used to boost the number of white blood cells. Growth factors are given by injection under the skin (subcutaneous) – the number of injections needed depends on individual circumstances.
Plasmapheresis or Plasma Exchange
Plasmapheresis can help with the effects of hyperviscosity which develops in up to 3 in 10 people with WM. It causes symptoms that may include nosebleeds, blurring or loss of vision, dizziness, headaches, drowsiness, poor concentration, confusion and shortness of breath.
During plasma exchange, you are hooked up to a sophisticated machine via two of your veins. Your blood leaves your body from one vein, is processed by the closed system in the machine and returned to your bloodstream through the other vein. The outpatient process typically takes 3–4 hours and is carried out in a specialist unit.
Your clinical team will work out how many plasma exchanges you need, and how often, before you start to have your main treatment.
Prevention of Infection
If you are receiving chemotherapy you may need to take medications to help prevent bacterial, viral and fungal infections as your immune system may be temporarily weakened.
This may involve taking an antibiotic, antiviral or antifungal medication. Prescribing of these varies in different centers. Sometimes a short-term antibiotic is needed, for example before an invasive dental or surgical procedure.
It is important to get all the vaccines that your doctor recommends.
You should be offered pneumococcal vaccination in the form of pneumococcal conjugate vaccine followed by pneumococcal polysaccharide vaccine at least 2 months later (this is the guidance in the UK – it may differ in other countries). If you develop recurrent infections, you may benefit from a wider range of vaccines against other bacteria that cause pneumonia and meningitis.
Live vaccines against polio, herpes zoster (shingles) and yellow fever are not recommended. However, there is a non-live vaccine against herpes zoster that is approved for use in immunocompromised patients. Ask your doctor about this.
Individuals with blood cancer can be vaccinated against COVID-19 as the vaccines do not pose a risk of infection. If you are receiving chemotherapy or immunosuppression, talk to your hospital doctor about when to get vaccinated. You may respond less well to vaccines if your immune system is diminished by your WM or treatment.
If you are less able to produce antibodies in response to infection because of your WM or your treatment, you may experience recurrent infections, such as chest infections, sinus infections or bladder infections. If you develop back-to-back infections and require repeated courses of antibiotics or admissions to hospital, then ask your doctor to check your immunoglobulin levels.
Your immunoglobulin levels give a measure of your capacity to produce antibodies. If they are low, in particular if your IgG level is less than 4 g/L, you may benefit from IVIG infusions, which can be given monthly into a vein.
IVIG consists of antibodies extracted from blood donations that have gone through manufacturing steps to the risk of transmitting an infection.
IVIG is a precious resource that is in short supply, so your case for receiving it is likely to be assessed by a panel of experts. Certain conditions need to be met, such as vaccination against bacterial infections, as mentioned above. Once IVIG is started, its use is limited to the smallest effective dose, frequency and duration.
Information based on Fast Facts for Patients: Waldenström Macroglobulinemia (Karger, 2022).