Taking nutritional supplements is common among multiple myeloma patients and other cancer patients. These supplements, including vitamins, minerals, and various plant compounds, may be important to keep the body healthy, aid in the treatment of myeloma, or to reduce negative side effects of treatment.

However, supplements, even those found naturally in foods, have the potential to interact poorly with chemotherapy or other treatments. Physicians typically agree that eating a balanced and nutritional diet is important, but they are often hesitant to recommend the use of certain supplements, since there may be little to no research to show that they are effective and safe in myeloma patients (see a related Beacon forum discussion). So, please discuss all supplements with your doctor before taking any.

If you and your doctor decide that certain supplements may be right for you, there are several important things to keep in mind. In general, supplements should be taken with food, unless otherwise indicated. If you are being treated with Velcade (bortezomib), avoid taking supplements on the days you receive Velcade, as they can diminish the efficacy of Velcade. If your doctor approves a supplement regimen, ask your doctor to provide specific instructions on when and how to take the supplements.

In order to help you decide which supplements you may want to discuss with your doctor, this article will provide for each nutrient: information on its potential purpose in multiple myeloma treatment, where to find it in your normal diet, and the suggested doses for myeloma patients.

Acetyl-L Carnitine

Some small studies suggest supplementing with acetyl-L carnitine, a nutrient normally made in sufficient amounts by the body, can help reduce the symptoms of peripheral neuropathy (nerve damage to arms and legs that is a common side effect of myeloma treatment). Acetyl-L carnitine may also protect heart cells from damage from Doxil (doxorubicin liposomal) treatment.

Acetyl-L carnitine is found in beef, pork, and milk. As a supplement for peripheral neuropathy, patients can try 500 milligrams twice a day with food. Up to 2 grams a day is safe, but over 5 grams a day can cause diarrhea, appetite changes, body odor, and rash.

Alpha Lipoic Acid

Alpha lipoic acid is an antioxidant that is commonly used in supportive therapy for peripheral neuropathy in people treated for multiple myeloma. It is an antioxidant that is normally made in the body, but people can also take extra alpha lipoic acid through supplements. Myeloma patients with peripheral neuropathy can take 300 milligrams to 1 gram daily, with 600 milligrams often recommended for up to four weeks.

Patients should be aware that one study done in myeloma cells in a lab found that alpha lipoic acid may reduce the effectiveness of Velcade treatment.

Calcium

People with multiple myeloma may take calcium along with vitamin D to help support their bones. However, bone breakdown during multiple myeloma also releases unhealthy amounts of calcium in the blood, so patients should consult their doctors before considering calcium supplements.

Curcumin

Curcumin, a compound found in the spice turmeric, may work to kill myeloma cells and prevent them from multiplying. For those who have the pre-cancer conditions monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma, curcumin may slow progression to active multiple myeloma, but this has not yet been supported by clinical research.

At the same time, patients should beware that curcumin can also suppress the immune system, which can be dangerous for people with multiple myeloma, smoldering multiple myeloma, or MGUS. For more information, please see the related Beacon news and discussion.

There is no standard established dose for curcumin in multiple myeloma. In the few small studies available on curcumin as a myeloma therapy, patients usually take about 4 grams daily spread out over many doses throughout the day. In India, where turmeric is popular in cooking, the average daily consumption is much less—60 milligrams to 200 milligrams through diet.

Enzymes

A mixture of the enzymes papain, trypsin, and chymotrypsin may weaken myeloma cells and increase the likelihood of responding to conventional chemotherapy. Anecdotal evidence suggests drinking papaya juice, which is rich in papain, may also be helpful in cancer therapy (see related Beacon news).

Eating papaya or drinking papaya juice generally poses little risk, though people who are pregnant, are allergic to kiwi fruits or figs, or have problems with blood clotting should avoid papain. Also, raw papain can irritate the skin.

There is little data on the effectiveness of this type of therapy or how much enzyme supplement to take for multiple myeloma. An ongoing Phase 3 trial is studying three daily doses of a product called Wobe Mugos E, which contains 100 milligrams of papain, 40 milligrams of trypsin, and 40 milligrams of chymotrypsin. Side effects of papain supplements, such as Wobe Mugos E, include throat and stomach irritation.

Fish Oils

Fish oils commonly contain plenty of omega-3 fatty acids, which may boost peripheral nerve health. For this reason doctors sometimes recommend them for peripheral neuropathy. Omega-3 fatty acids may also work against cancers by reducing inflammation.

Omega-3 fatty acids perform many important functions in the body and are an essential part of a healthy diet. Healthy patients are recommended to take 1.1 grams of omega-3 fatty acids a day for women and 1.6 grams a day for men. No recommendations specifically for myeloma patients were found. Patients should be careful not to take more than 3 grams a day without medical supervision because of an increased risk of bleeding.

The science on the effects of omega-3 fatty acids on multiple myeloma is still preliminary—two studies from the 1990s showed certain omega-3s kill myeloma cells in mice. For those interested in trying fish oils in a clinical trial, a trial is recruiting volunteers who have MGUS or smoldering multiple myeloma for a study on whether omega-3 supplements will delay or prevent the progression of these diseases to symptomatic multiple myeloma. The trial is starting patients on 1.25 milligrams three times a day, and the dosage will be increased for patients who can tolerate it.

Ginger

Ginger is a well-known home therapy for nausea. The latest science supports using ginger alongside prescribed nausea medication to reduce nausea from chemotherapy (see related Beacon news). The study showed that 0.5 gram to 1 gram of ginger daily for three days before chemotherapy and the first three days of chemotherapy significantly reduced nausea.

Glutamine

Supplements of the amino acid glutamine may help with several major side effects of high dose-chemotherapy and bone marrow transplantation. Small studies have shown it may reduce peripheral neuropathy, mouth sores and mouth ulcers, and infections.

Patients can take 15 grams of a pure L-glutamine powder twice daily for a total of 30 grams.

Green Tea

A compound found in green tea, called epigallocatechin-3-gallate (EGCG), may aid in killing myeloma cells and prevent myeloma cells from multiplying. However, it may also block the anti-cancer activity of Velcade, leading researchers to advise people with multiple myeloma undergoing Velcade therapy to avoid green tea products and EGCG supplements (see related Beacon news).

For people with MGUS or smoldering multiple myeloma, the compounds in green tea may slow down or prevent their pre-cancer conditions from progressing to multiple myeloma. Since most MGUS and smoldering myeloma patients are not actively treated, there is no worry of interference with chemotherapy. One Phase 2 clinical trial is studying the effects of a daily green tea extract on people with MGUS and smoldering myeloma. The trial is recruiting participants in Detroit.

Iron

Anemia (low red blood cell counts) is a symptom of multiple myeloma and is also a common side effect of many myeloma treatments. Iron supplements may help certain people with their anemia. Anemia is often treated with a prescription hormone called erythropoietin that stimulates red blood cell production. In severe cases, blood transfusions may be necessary.

For those whose anemia therapy would get a boost from iron, doctors may recommend an oral iron supplement or, if that is not enough, intravenous iron. In addition, patients can try including iron-rich foods in their diet such as dried beans, fortified cereal, beef, and eggs.

At the same time, people with multiple myeloma who get blood transfusions are at risk for having too much iron in their bodies, so iron supplements are not right for all myeloma patients. Doctors can tell patients how much iron is needed, depending on their condition.

Magnesium

Magnesium may help with peripheral neuropathy. It also helps regulate calcium levels and can help strengthen bone. Green leafy vegetables, almonds, cashews, and halibut are all good sources of this essential mineral.

People with multiple myeloma can also take 250 milligrams of magnesium twice daily through an over-the-counter supplement, or they might get a prescription for a daily 400-milligram supplement, depending on how much magnesium their doctors find in blood tests. Patients should beware that too much magnesium can cause diarrhea.

Potassium

Doctors may recommend potassium for people getting treated for multiple myeloma to help with peripheral neuropathy. Patients can get potassium from food sources such as sweet potatoes, bananas, citrus fruits, peas, red meat, and chicken, or their doctor may recommend potassium supplements.

There are no documented cases of people getting too much potassium from food, but supplements can cause hyperkalemia, a dangerous condition than can lead to sudden cardiac arrest. Since the kidneys work to remove extra potassium from the body, people with multiple myeloma, which often reduces kidney function, might be especially vulnerable. Multiple myeloma patients should be especially careful to take potassium supplements only under direction from their doctors.

Resveratrol

Resveratrol, a compound abundant in grape skins, may kill myeloma cells, prevent myeloma cells from multiplying, and enhance the effects of some common chemotherapy drugs (see related Beacon news).

Those interested in including more resveratrol in their diet can enjoy grapes, purple grape juice, red wine, peanuts, blueberries, and cranberries.

There are also many resveratrol supplements available on the market. However, because there have not been any completed clinical trials on resveratrol in multiple myeloma therapy, there is no established dosage. A Phase 2 clinical trial was studying the effects of 5 grams daily of a formulation of resveratrol in multiple myeloma patients. However, the trial was suspended earlier this year after several patients developed kidney failure (see related Beacon news).

Vitamin B

B vitamins, including vitamin B-1 (thiamine), vitamin B-2 (riboflavin), vitamin B-6, vitamin B-12, and folic acid, are important for the formation of red blood cells, enhance the immune and nervous systems, and more. People with multiple myeloma often have low red blood cells counts and can suffer from peripheral neuropathy, so getting enough B vitamins may be especially important for those with multiple myeloma.

Good food sources of B vitamins include fortified breakfast cereal; other fortified grain products; animal products such as fish, poultry, meat, and dairy; vegetables such as carrots, peas, and leafy greens; fruits such as avocadoes, grapes, and dates; and beans.

Vitamin B-1 and vitamin B-12 are so common in foods, people rarely need to take supplements for them. For the other B vitamins, supplements commonly come in a B-vitamin complex formula that includes many or all of the B vitamins in one pill.

Recommended amounts for multiple myeloma patients with peripheral neuropathy include 50 milligrams of vitamin B-6 daily (but not more than 100 milligrams a day) and 1 gram of folic acid daily.

Vitamin C

As an antioxidant, vitamin C helps protect cells from environmental damage that may lead to cancer. It also functions in protecting the immune system. The best protective benefits seem to result from obtaining vitamin C through fruits and vegetables, but the vitamin is still one of the most popular supplements for people with cancer.

Myeloma patients who are interested in vitamin C supplements should be aware that taking antioxidants on the same day as Velcade treatment reduces Velcade’s therapeutic effects (see related Beacon news). However, patients can still enjoy fruits and vegetables that are naturally high in vitamin C, such as red peppers, citrus fruits, kiwi, and broccoli.

Vitamin D

Vitamin D works with calcium to build bone, and recent research suggests it might be important in reducing some signs and symptoms of multiple myeloma. Supplements may help people with multiple myeloma deal with chronic bone pain, weakness, fatigue, and peripheral neuropathy. Meanwhile, vitamin D deficiency may be associated with poorer multiple myeloma prognoses (see related Beacon news).

Patients should aim to get 800 international units (IU) to 1,200 IU of vitamin D daily. Getting out in the sun every day for 15 minutes can go a long way toward keeping vitamin D levels up. Including fortified cereal and fortified milk, cheese, and other milk products in the diet can also prove beneficial. For those who cannot eat or drink dairy products, most alternatives, such as soy milk, rice milk, and almond milk, are fortified as much as cow’s milk. Vitamin D is also present naturally in fatty fish, such as salmon or tuna.

Many people do not get enough vitamin D through sun exposure and their diet, however. A daily supplement with 400 IU to 800 IU of vitamin D2 (ergocalciferol) or D3 (cholecalciferol) can help.

Vitamin E

For those suffering from peripheral neuropathy, vitamin E supplements may help. This antioxidant vitamin may protect nerves during therapy, especially with Velcade or thalidomide.

Additionally, Vitamin E may help heal mouth sores caused by chemotherapy. In a 2003 entry, multiple myeloma blogger Jon Siegel wrote about applying the contents of a vitamin E capsule to his mouth sores. He found he had “a relatively easy time of it compared to other folks” who had gone through chemotherapy.

For food sources of vitamin E, look to almonds, sunflower seeds and oil, peanut butter, and safflower oil. If taking a supplement, 400 IU daily is recommended.

For more information about nutrition for myeloma patients, see Part 1 in the series.  Feel free to post as a comment any recommendations your physicians made about these or additional supplements, and please remember to always consult with your doctors before taking any new supplements.

Papain is an enzyme that breaks down proteins. One such protein, called fibrin, makes up the protective layer of cancer cells. Papain degrades fibrin and damages this protective layer, making the cells more susceptible to immune response or chemotherapy. The compound also hinders tumor growth and prevents it from spreading to other parts of the body.

Papaya plants contain high concentrations of papain, not only in the fruit, but also in the stem, leaves, fruit skin, and seeds. The compound has a toxic effect on plant-eating insects, protecting the unripe papaya from the insects. It decreases naturally in concentration as the fruit ripens.

Synthetically, papain is combined with the enzymes trypsin and chymotrypsin in an oral enzyme product called Wobe-Mugos E. Wobe-Mugos E has been used in Europe to bolster chemotherapy since 1977.  Since then, studies have been conducted to verify the treatment efficacy of Wobe-Mugos E in multiple myeloma.

Scientists at the University of Brastislava’s Clinic of Hematology and Transfusion Medicine in the Slovak Republic determined that multiple myeloma patients undergoing chemotherapy achieved a greater remission response if they were supplemented with Wobe-Mugos E for more than six months, compared to patients who were not.

Patients in the Wobe-Mugos E group received two tablets of the oral enzyme daily for one year after starting chemotherapy, then one tablet daily for the remainder of their treatment. Supplementation with Wobe-Mugos E took place for a median of 41 months. Among patients who received Wobe-Mugos E, 97.6 percent achieved complete response, partial response, or disease stability after chemotherapy, compared to 69.7 percent of patients who received a placebo.

In addition, the median survival for Stage 3 patients nearly doubled with Wobe-Mugos E supplementation. The therapy proved safe, causing gastrointestinal symptoms in only 3.6 percent of patients. However, because group assignments were not random, the study’s results may have been influenced. Scientists expressed enthusiasm but recommended further evaluation. The journal Cancer Chemotherapy and Pharmacology (abstract) published their results in June 2001.

Several accounts from cancer survivors suggest that eating papaya offers the same antitumor benefits as synthetic forms of papain. In a book entitled Cancer: The Complete Recovery Guide, author John Chamberlain cites the story of a woman whose friend overcame stomach cancer in six months by juicing the skin of unripe papaya. He provides a recipe that explains how to do so.

In food, papain poses little to no health risk. Medicinal doses are also safe for most adults to consume, although patients may experience throat and stomach irritation. In instances of pregnancy, allergy to kiwi or figs, and blood clotting disorders, papain may pose a health risk and should be avoided. When in contact with the skin, raw papain may cause blistering or irritation.

Dietary supplements containing papain are available on the market. Patients should be advised that the Food and Drug Administration (FDA) does not require the manufacturers of dietary supplements to register their products before they enter the market. However, the FDA does monitor the supplements’ safety once they are on the market. Tips on how to choose supplements are available on the FDA’s Web site.

While little research has been done to illuminate the effects of papain in treating multiple myeloma, the enzyme and the fruit in which it is found offer a promising development in the fight against the disease, and their effects should be further evaluated.

In the meantime, patients should consult their physicians before taking papain supplements or changing their dietary patterns to include papaya fruit or juice.