Melphalan and prednisolone MP

• 4 day courses of M&P (M 6-9mg/m2/day PO; P 40-100mg/day PO) at 4-6 week intervals achieve >50% reduction of paraprotein in 50-60% patients; monitor response by serum/urine paraprotein level (serum free light chains in most non-secretors); response often slow; continue treatment to maximum response (9-12 months); CR uncommon.

• Patients with >50% response may achieve plateau phase (stable paraprotein without further treatment; median duration 12-18 months); maintenance chemotherapy in plateau ineffective and toxic; monitor paraprotein 6-8 weekly to detect progression; further responses to M&P after durable plateau; melphalan resistance ultimately develops in all patients.

• Median survival ~36 months; well tolerated; remains appropriate first line treatment for elderly patients treated outside a clinical trial; side effects myelosuppression and steroid toxicity (add PPI or H2 antagonist).

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