Initial Treatment for Multiple Myeloma Meeting CRAB or SLiM Criteria

Diagnostic Confirmation Before Treatment

The International Myeloma Society recommends confirmation of diagnosis with ≥10% clonal plasma cells on bone marrow examination or biopsy-proven plasmacytoma 1
The European Society for Medical Oncology suggests evidence of end-organ damage (CRAB criteria) attributable to the plasma cell disorder 3
A complete staging workup including serum/urine protein electrophoresis, immunofixation, serum-free light chains, skeletal survey, and cytogenetics (FISH for del(17p), t(4;14), t(14;16), del(17p)) is recommended by the International Myeloma Society 5

The American Society of Clinical Oncology recommends induction therapy with bortezomib, lenalidomide, dexamethasone (VRd) for 3-4 cycles followed by autologous stem cell transplantation (ASCT) for transplant-eligible patients 1
The National Comprehensive Cancer Network suggests melphalan 200 mg/m² IV as the standard preparative regimen before ASCT 6
For transplant-ineligible patients, the European Society for Medical Oncology recommends the combination of bortezomib, melphalan, prednisone (VMP) for 8-12 cycles 5

The International Myeloma Society recommends bortezomib-based regimens for patients with renal impairment (creatinine >2.0 mg/dL or CrCl <40 mL/min) 1
The American Society of Clinical Oncology suggests aggressive hydration with normal saline as first-line management for hypercalcemia (>11.5 mg/dL) 1
The European Society for Medical Oncology recommends long-term bisphosphonates (zoledronic acid or pamidronate) to reduce skeletal-related events in patients with bone lesions 2

The National Comprehensive Cancer Network advises against delaying treatment in patients with clear CRAB criteria, as this leads to increased morbidity and mortality 1
The International Myeloma Society recommends avoiding the classical VAD regimen (vincristine, adriamycin, dexamethasone) as it is inferior to modern combinations and causes stem cell damage 6