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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Myeloma emergencies and supportive treatment

Haematology and transfusion · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Parallel stabilisation and clone control

Cord compression, severe hypercalcaemia, cast-nephropathy acute kidney injury, sepsis, hyperviscosity, pathological fracture and tumour lysis can cause irreversible harm before routine review.

Action: Use ABCDE, analgesia, ECG and focused neurological and volume assessment; send FBC, renal, calcium, phosphate, urate, LDH, cultures and clonal tests and obtain syndrome-specific imaging. Stabilise immediately, involve haematology and the relevant acute specialty, and start rapid anti-myeloma therapy when clone-driven injury is established.

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.
  • Severe hypercalcaemia needs ECG, careful isotonic-fluid replacement when depleted, cessation of aggravating medicines and an intravenous bisphosphonate after renal assessment.
  • Myeloma-induced acute renal disease requires immediate bortezomib- and dexamethasone-based combination treatment under NICE NG35, alongside correction of volume, calcium, sepsis and nephrotoxins.
  • Do not use plasma exchange for myeloma-induced acute renal disease; urgent reduction of light-chain production is central, and dialysis follows ordinary emergency renal indications.
  • Clinical hyperviscosity with visual, mucosal or neurological findings requires urgent plasma exchange; do not wait for viscosity or omit systemic anti-myeloma follow-on therapy.
  • Zoledronic acid is first-line bone protection in NICE NG35 when suitable; arrange dental assessment, assess renal function and monitor calcium and osteonecrosis risk.
  • Immunomodulatory drugs with steroids need thrombosis assessment; NICE NG89 supports aspirin 75 or 150 mg or LMWH during therapy, selected by VTE and bleeding risk.

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.

Confusion, dehydration, vomiting, constipation, shortened QT interval or arrhythmia with markedly raised corrected or ionised calcium requires same-day treatment and cardiac monitoring.

Rapid creatinine rise, oliguria, very high involved free light chain or concurrent hypercalcaemia suggests cast nephropathy and needs immediate clone-reduction planning.

Fever, hypothermia, rigors, confusion, hypotension, tachypnoea or new oxygen requirement during myeloma treatment requires urgent sepsis assessment even without neutropenia.

Headache, blurred vision, retinal venous engorgement, mucosal bleeding or neurological change with a large paraprotein suggests symptomatic hyperviscosity and urgent plasma exchange.

A painful limb deformity, inability to weight bear, new vertebral collapse or impending long-bone fracture needs urgent orthopaedic and imaging assessment.

Investigation priorities

01
First-line emergency laboratory panelFirst stepFirst line

Identify immediately reversible metabolic, renal, infectious and marrow threats.

02
First-line: serum free light chains and clonal markersFirst line

Quantify the nephrotoxic clone and establish an urgent response baseline.

Management branches

New neurological deficitProtect cord function

Back pain accompanies weakness, sensory, gait or sphincter change.

  1. Immobilise if instability is suspected, give analgesia, document neurology and contact the MSCC service immediately.
  2. Give dexamethasone 16 mg orally or equivalent parenterally and arrange whole-spine MRI within 24 hours.
  3. Coordinate urgent surgery, radiotherapy or systemic treatment, then taper steroid after definitive treatment starts.

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.Monitor glucose, infection, mood, weakness and gastrointestinal risk and prescribe proton-pump-inhibitor protection. Stop if imaging excludes MSCC. Seek haematology advice before steroid in radiologically suspected but unconfirmed lymphoma or myeloma without neurological signs because diagnosis may be altered.
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.Check creatinine, calcium, phosphate, magnesium, vitamin D and dental status. Severe renal impairment needs individual risk-benefit review; adapt repeated dosing for deterioration. Counsel on jaw pain and avoid invasive dental work when possible. Do not add calcium during active hypercalcaemia.
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Sources and review status9 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.

  • NICE NG35 myeloma diagnosis and managementCurrent UK renal rescue, bone disease and complication recommendations, reviewed in February 2026.
  • NICE NG234 spinal metastases and metastatic spinal cord compressionUrgent whole-spine imaging, dexamethasone dose and definitive-treatment pathway.
  • NICE NG253 suspected sepsis in adultsCurrent adult sepsis risk assessment, initial management and escalation.
  • NICE NG89 venous thromboembolism preventionAspirin or LMWH prophylaxis during immunomodulatory myeloma treatment with steroids.
  • Zoledronic acid 4 mg Summary of Product CharacteristicsExact tumour-induced hypercalcaemia and skeletal-event doses, infusion, renal and dental safety.
  • Bortezomib Summary of Product CharacteristicsExact licensed bortezomib schedule, renal use, neuropathy and safety modification.
  • Aciclovir 400 mg Summary of Product CharacteristicsAntiviral prophylaxis and renal safety.
  • Kent and Medway daratumumab-VCd protocolNHS support for aciclovir 400 mg twice daily with proteasome inhibitor and anti-CD38 treatment.
British Society for Haematology apheresis guideline
UK therapeutic plasma-exchange principles for symptomatic hyperviscosity.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom