At-Home Management of Aplastic Phase Following High-Dose Melphalan and Autologous Haematopoietic Stem Cell Transplantation for Multiple Myeloma Patients: A Pilot Study

After high-dose melphalan with autologous peripheral hematopoietic stem cell transplantation (APHSCT) long hospital stays in the aplastic phase are expensive, lead to increased risk of hospital infections and to increasing pressure on available hospital beds.

The aim of this pilot study was to analyze the feasibility of a home care program (HCP) for Multiple Myeloma (MM) patients receiving high-dose melphalan 200 mg/mq (HDM), and undergoing APHSCT to be at home for the aplastic period, without daily hospital visits.

Between July 2010 and July 2011 supportive care in the aplastic phase after APHSCT was transferred from the hospital to the home setting. Eligible subjects included patients with de novo, symptomatic, MM treated with a single course of HDM, followed by APHSCT. In the home care cohort, patients were required to have an available caregiver at home to help monitor patient’s condition. In case of patient refusal or ineligible to the HCP treatment, these patients were registered in the inpatient cohort as the control arm. Patients were discharged to their private home the day after stem-cell reinfusion in the absence of the contraindications. Hospital transplant nursing staff, delivered all supportive care at home and this included blood sampling from the central indwelling intravenous catheter for laboratory investigations and cultures, transfusion of blood products, and infusion of parenteral antibiotics. The transplant physician carried out the survey to the home-patient twice a day, with no access to hospital. In case of unexpected problems, patients could consult the transplant physicians 24 hours a day at the transplant center.

39 consecutive MM patients were treated with HDM and AHSCT. 11 patients agreed to be managed during the aplastic phase at home; 28 patients were not eligible (4 did not have an available caregiver; 4 have not accepted the management at home; 20 patients lived more than 15 kilometers from the hospital). In the 11 transplant cycles in the home care cohort, patients were discharged on the first day after stem-cell reinfusion in all cases. The patients in the hospital cohort were hospitalized for a median of 18 days The home care patients spent most of the aplastic period at home, for a median of 12 days, with 4 days in hospital. Readmissions occurred in 2/11 of home care patients and were because of fever. Febrile neutropenia occurred for a median of 3 and 7 days in the aplastic period for patients in the hospital and home care setting respectively. Other side effects were mild and comparable between the two study groups. No transplant related mortality occurred in both cohort of patients.

An HCP using HDM is feasible. No unexpected emergencies were encountered, and toxicity did not seem different from the full hospitalization schedule during the aplastic period. We have not had to compromise on patient safety and have gained on quality of life and improved the allocation of available hospital beds

No relevant conflicts of interest to declare.