Lenalidomide, pomalidomide and the newer cereblon modulators all cause neutropenia, and anti-CD38 antibodies add hypogammaglobulinaemia. Infection is the leading non-myeloma cause of death in the first months of treatment. A patient on these regimens with fever needs a blood count and empirical broad-spectrum antibiotics within an hour if neutropenic. Prophylaxis — antivirals against herpes zoster, pneumocystis prophylaxis where indicated, vaccinations and immunoglobulin replacement for recurrent infections with low IgG — reduces risk.
- Check a full blood count urgently in any febrile myeloma patient on therapy.
- Start empirical antibiotics within an hour if neutropenic.
- Prescribe acyclovir or valacyclovir prophylaxis with proteasome inhibitors and anti-CD38 antibodies.
- Check IgG in recurrent infections; consider immunoglobulin replacement.
- Keep influenza, pneumococcal and COVID-19 vaccination up to date.
Why it matters
As regimens intensify, infection prevention becomes as important as the antimyeloma effect.
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