Synopsis
Recognise and stabilise time-critical myeloma complications, reverse each mechanism and integrate bone, infection, thrombosis, renal and treatment support with rapid clone control.
- Treat the presenting syndrome and the clone in parallel: supportive measures alone cannot reverse continuing light-chain, marrow or skeletal injury.
- Suspected malignant spinal cord compression needs urgent whole-spine MRI as soon as possible and always within 24 hours, with immobilisation when instability is possible.
- NICE recommends dexamethasone 16 mg orally or equivalent parenterally immediately for neurological signs of cord compression, then 16 mg daily while surgery or radiotherapy is awaited.
Key red flags
New severe back or radicular pain, weakness, sensory change, gait disturbance or bladder and bowel dysfunction is spinal cord or cauda equina compression until urgently excluded.
Investigation priorities
Identify immediately reversible metabolic, renal, infectious and marrow threats.
Quantify the nephrotoxic clone and establish an urgent response baseline.
Management branches
Back pain accompanies weakness, sensory, gait or sphincter change.
- Immobilise if instability is suspected, give analgesia, document neurology and contact the MSCC service immediately.
- Give dexamethasone 16 mg orally or equivalent parenterally and arrange whole-spine MRI within 24 hours.
Key medicines
Dexamethasone for malignant cord compressionGive 16 mg orally immediately, or the equivalent parenteral dose, for neurological symptoms or signs; continue 16 mg orally or parenterally each day while surgery or radiotherapy is awaited, then taper gradually after definitive treatment starts.
Zoledronic acidFor tumour-induced hypercalcaemia with corrected calcium at least 3.0 mmol/L, give 4 mg intravenously once over at least 15 minutes after volume assessment. For skeletal-event prevention, 4 mg intravenously every 3–4 weeks is licensed, with renal modification.