. Author manuscript; available in PMC: 2019 Jul 10.

Published in final edited form as: Am Soc Clin Oncol Educ Book. 2017;37:575–585. doi: 10.14694/EDBK_175171

TABLE 3.

Complications of High-Dose Melphalan

Complication	Incidence	Implications for the Older Patient
Myelosuppression	Universal, with the exception of truly nonablative regimens	Prolonged myelosuppression increases risks of life-threatening infections; thus, strategies that may accelerate neutrophil recovery in older patients could be beneficial.
Myelosuppression	Universal, with the exception of truly nonablative regimens	Filgrastim is beneficial in shortening the duration of neutropenia.
Mucositis	10%–20% with high-dose melphalan	Severe mucositis may require opioid analgesia for pain control, which is less well tolerated by older patients, Risk of aspiration from severe mucositis may be more frequent for older patients.
Mucositis	10%–20% with high-dose melphalan	Cryotherapy (ice chips) has been shown to reduce the risk of severe mucositis, Palifermin has not.
Infections	> 50% of patients will have some infectious complication, The most common is neutropenic fever or Gram-positive sepsis,	For older patients, the ability to recover from infectious complications may be affected by prior comorbid states and ability to tolerate anti-infective therapies such as foscarnet or amphotericin B.
Infections		Older patients require the same infectious prophylaxis as younger patients; zoster prophylaxis is required until immunity is documented and may be required for life.
Gastrointestinal toxicities	Loss of appetite is almost universal	Gastrointestinal toxicities can be more common and more severe for older patients.
	Severe nausea and emesis are rare with current antiemetic regimens	It is essential to maintain good hydration and adequate electrolyte replacement.
	Severe diarrhea can be seen with melphalan	Nutritional intervention may need to be considered earlier.
Pulmonary toxicities	Pneumonitis and diffuse alveolar hemorrhage rare after high-dose melphalan	Patients with pre-ASCT pulmonary comorbidities are at higher risk for pulmonary toxicities.
Hepatic toxicities	SOS/VOD rare with high-dose melphalan	Similar risk as younger patients
Cardiac toxicities	Arrhythmias	Atrial fibrillation is a common occurrence after high-dose melphalan.
Cardiac toxicities	Congestive heart failure
Engraftment syndrome	Rash, fever, and occasionally diarrhea and renal dysfunction	Early institution of steroid therapy is important to prevent DAH.
Graft failure	Rare	Older patients collect a lower cell dose.

Abbreviations: SOS, sinusoidal obstruction syndrome; VOD, veno-occlusive disease; ASCT, autologous stem cell transplantation; DAH, diffuse alveolar hemorrhage.