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Referral
MGUS (Monoclonal Gammopathy)
Scope
Several disorders are associated with the presence of a monoclonal protein in the blood, including Multiple Myeloma, Lymphoma, Chronic Lymphocytic Leukaemia (CLL) and MGUS.
MGUS is defined by a low level of monoclonal protein (less than 30 g/L) and the absence of anaemia, hypercalcaemia, lytic bone lesions, and renal failure attributable to a plasma cell disorder or lymphoma. It is asymptomatic and very common; found in 3% of over 70 years, and up to 10% in over 80 years of age.
MGUS does not require treatment but there is a potential to progress to symptomatic multiple myeloma (MM) or lymphoma and therefore the condition needs long term clinical follow-up once detected.
Signs and Symptoms
If fever, malaise, bone pain, lymphadenopathy, hepatosplenomegaly, kidney problems, exclude significant causes of a monoclonal protein:
Multiple Myeloma
- Patients may present with bone pain, lytic lesions in the bones, impaired renal function, hypercalcaemia, isolated normocytic anaemia, or pancytopenia
- To diagnose, arrange the same tests as for MGUS. However, there will be higher levels of monoclonal protein plus other abnormalities, as above
- Arrange urgent referral if there is associated spinal cord compression, hypercalcaemia, or renal failure
- All require haematologist assessment and management
Lymphoma
- Assess for enlarged lymph nodes and/or hepatosplenomegaly. Cytopenias may also be present. If suspected refer for Haematology assessment
CLL
- Associated with an elevated lymphocyte count. Manage according to the CLL pathway
Amyloidosis
- May be associated with: Restrictive cardiomyopathy, unexplained gastrointestinal symptoms, peripheral neuropathy and carpal tunnel syndrome.
Risk of progression
Overall, approximately 1% of patients with MGUS progress to myeloma each year. Risk factors associated with a higher chance of progressing to symptomatic disease are listed below.
| Assess 3 factors: | |
| paraprotein level > 15 g/L | 1 point |
| abnormal serum free light chain ratio | 1 point |
| non-IgG protein (i.e., IgA, IgE) | 1 point |
| Number of Factors | Risk of progression at 20 years |
| No abnormal factors | 5% |
| 1 factor | 21% |
| 2 factors | 37% |
| 3 factors | 58% |
Bloods - full blood count, creatinine, calcium, albumin, serum protein electrophoresis (SPE) with immunoglobulin levels, and urine Bence-Jones Protein (BJP).
MGUS can often be managed with regular monitoring through general practice. A suggested treatment algorithm is illustrated below. It is derived from the British Committee for Standards in Haematology guidelines 1.
Suggested algorithm for the investigation of newly detected M-protein
Referral Criteria
High Risk
- Symptomatic of suspected myeloma or lymphoma
- Abnormal physical signs suggestive of underlying myeloma or lymphoma
- Unexplained abnormal investigation results (blood test or x-rays)
- IgG paraprotein more than 15g/L
- IgA paraprotein or IgM paraprotein more than 10g/L
- Any IgD or IgE paraprotein irrespective of concentration
Low Risk, group who clinician is concerned with during primary care follow up
- IgG paraprotein less than 15g/L
- IgA paraprotein or IgM paraprotein less than 10g/L
- Asymptomatic
- No other abnormal results
- BJP positive or negative
- Uninvolved immunoglobulins low or normal
Referral Instructions
e-Referral Service Selection
- Specialty: Haematology
- Clinic Type: Not otherwise specified
- Service: DRSS-Eastern-Haematology-Devon CCG- 15N
Referral Forms
Pathway Group
This guideline has been signed off by NEW Devon CCG.
Publication date: July 2016
