Benzodiazepine & Zolpidem Usage in Multiple Myeloma Patients Undergoing Transplantation

Abstract

Background Multiple myeloma (MM) patients (pts) are older and have poorer quality of life (QOL) compared to pts with other hematologic malignancies (Nielsen et al, Eur J Haematol 2017). Autologous hematopoietic stem cell transplantation (HCT) acutely exacerbates psychosocial distress & insomnia. These symptoms are often treated with benzodiazepines and zolpidem-class drugs (B/Z Rx) that come with serious toxicities in older adults. B/Z Rx patterns in HCT recipients, particularly among MM patients who tend to be older with more co-morbidities, are unknown. Methods We conducted a retrospective cohort study including all pts with MM or light-chain amyloidosis who underwent autologous HCT at our institution from 1/1/17-12/31/18. We identified B/Z Rx at 3 timepoints: (1) pre-HCT baseline; (2) discharge, or D+14 for outpatient HCT; and (3) D+100 follow-up. Results 205 pts (43% female) underwent HCT, 184 (90%) as inpatient (inpt) and 21 (10%) as outpatient (outpt). The median age was 61; 27 pts (13%) were ≥ 70. 174 pts (85%) had received melphalan 200 mg/m2 conditioning; the remainder received 140 mg/m2. 28% of pts (n=58) had ≥ 1 B/Z Rx at all timepoints, while 38% (n=77) had no Rx at any timepoint. As shown in Figures 1 & 2: 33% of pts (n=67) had B/Z Rx at baseline, 57% (n=116) at discharge, and 51% (n=104) at D+100. Among B/Z-naive pts at baseline (n=138), the D+100 B/Z Rx rate was significantly higher among those with any B/Z Rx at discharge than those without (34% vs. 11%, p The most common B/Z Rx's were lorazepam (55% of pts, n=113) and zolpidem (12%, n=24). Of the 113 pts with lorazepam Rx, 35% (n=40) had a specific indication (2nd-line management of nausea/vomiting) without listing a distress-related symptom (e.g., anxiety). After excluding these 40 pts, overall rates of B/Z Rx fell to: 33% (54/165) at baseline, 47% (77/165) at discharge, and 48% (79/165) at D+100. Conclusions 62% of MM pts undergoing HCT received ≥ 1 B/Z Rx peri-HCT, a substantially higher rate than the 13% prevalence in the US population. ∼1/4 of pts experienced escalation of B/Z Rx therapy. Among B/Z-naive pts at baseline, pts prescribed B/Z Rx at discharge were 3x as likely to have continued B/Z Rx at D+100. These findings demonstrate the prevalence and persistence of B/Z Rx use despite their known toxicities. Limitations of our single-center study include an inability to assess how frequently prn Rx were actually taken or prescribed by local oncologists. Nevertheless, we are now investigating non-pharmacologic interventions to improve distress & insomnia in HCT recipients with the eventual goal of lowering B/Z Rx usage.