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Textbook/Haematology and transfusion/Multiple myeloma/Rapid
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Multiple myeloma

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Myeloma with cord compression, renal failure or hypercalcaemia

New neurological deficit, severe hypercalcaemia, sepsis, hyperviscosity or rapidly worsening light-chain acute kidney injury needs immediate treatment before the complete elective staging process finishes.

Action: Use ABCDE assessment, obtain FBC, calcium, renal, electrolytes, serum electrophoresis, immunofixation and free light chains, group samples and urgent whole-spine MRI for cord symptoms; give cause-specific fluids, dexamethasone, antiresorptive, antibiotics, decompression or plasma exchange with immediate myeloma-team involvement.

Synopsis

Diagnose active myeloma using clonal plasma cells plus myeloma-defining events, separate it from precursor gammopathy and deliver fitness-, biology- and transplant-directed treatment with organ-protective support.

  • Screen suspected myeloma with serum protein electrophoresis plus serum free light chains, then serum immunofixation; no single negative paraprotein test excludes non-secretory or light-chain disease.
  • Confirm clonal plasma cells with marrow aspirate and trephine morphology and flow, and send plasma-cell FISH on enriched cells for prognosis.
  • First-line skeletal imaging is whole-body MRI or whole-body low-dose CT; do not use isotope bone scanning because purely lytic disease may be missed.

Key red flags

Severe back pain with weakness, sensory change or sphincter dysfunction is malignant spinal cord compression until urgent whole-spine MRI proves otherwise.

Renal light-chain injury

Rapid creatinine rise with high involved free light chain, bland urine or disproportionate protein pattern suggests cast nephropathy.

Investigation priorities

01
First-line: SPEP plus serum free light chainsFirst stepFirst line

Detect intact monoclonal immunoglobulin and light-chain-only disease.

02
First-line whole-body imagingFirst line

Identify lytic lesions, focal marrow disease, fracture and plasmacytoma.

Management branches

Suspected myelomaDetect clone and organ injury together

Bone pain, anaemia, renal impairment, hypercalcaemia, infection or paraprotein raises suspicion.

  1. Send FBC, calcium, renal, SPEP, immunofixation, free light chains, immunoglobulins and emergency-directed tests.
  2. Arrange marrow with flow and FISH and whole-body MRI or low-dose CT, escalating cord, renal or calcium emergencies immediately.

Key medicines

Daratumumab-based transplant inductionUse the exact NICE TA763 centre protocol combining subcutaneous daratumumab 1,800 mg with bortezomib, thalidomide and dexamethasone for induction, then autologous transplant and protocol consolidation.
Daratumumab with lenalidomide and dexamethasoneGive daratumumab 1,800 mg subcutaneously weekly in cycles 1–2, every 2 weeks in cycles 3–6 and every 4 weeks thereafter, with protocol lenalidomide days 1–21 of 28 and weekly dexamethasone adjusted for age and frailty.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom