Prevention of viral infections in patients with multiple myeloma: the role of antiviral prophylaxis and immunization

Abstract

Viral infections are a major cause of morbidity and mortality in patients with myeloma. Over the last decade, treatment of myeloma has undergone a paradigm shift with the use of immunomodulatory drugs, proteasome inhibitors and autologous stem cell transplantation, resulting in changes to risk periods and risk factors for viral infection. Viral infections affecting this patient group fall broadly into reactivation of latent viral infections (e.g., varicella zoster and hepatitis B) and acquisition of acute viral respiratory infections. The periods following autologous stem cell transplantation and progressive disease are identified as increased risk for viral infections. This review focuses on evidence-based prevention strategies for key viral infections, particularly approaches to prophylaxis and immunization. Recommended prevention strategies are summarized using a risk-stratified approach. Further studies evaluating preventative measures for newly identified risk periods are required.

Keywords:

• myeloma
• prevention
• risk
• treatment
• viral infection

Financial & competing interests disclosure

BW Teh is supported by the National Health and Medical Research Council Scholarship. MA Slavin has received research funding and honoraria from Pfizer, Gilead, and Merck Sharpe and Dohme. SJ Harrison has received research funding and honoraria from Celgene, Novartis, Amgen, Takeda, Sanofi and Janssen Cilag, and research funding from Abbvie.

Key issues

• Over the past decade, treatment for myeloma has undergone a paradigm shift with the use of immunomodulatory drugs, proteasome inhibitors and autologous hematopoietic stem cell transplantation (ASCT), and patterns and risks of viral infection for patients with myeloma have evolved with these therapies.

• The risk period for reactivation of latent viral infection (e.g., hepatitis B) is post-ASCT and maintenance treatment periods. In contrast, the risk period for acquisition of respiratory viral infection is with disease progression and maintenance treatment.

• In patients with myeloma, treatment-related risk factors for viral infection include lymphopenia, receipt of bortezomib and ASCT.

• Prophylaxis against herpes simplex, varicella zoster, hepatitis B and influenza is supported by available evidence. The role of prophylaxis for other viral pathogens remains undefined.

• Development of new antiviral agents may offer new approaches to prevention. For example, clinical trials of DAS-181 and GS 5806 are currently in progress for parainfluenza and respiratory syncytial virus infections, respectively.

• More research is required to evaluate preventive measures for patients with progressive disease and to individualize infection risk assessment, especially in heavily treated patients with myeloma.

Notes