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New Guidelines Issued in the Treatment of Multiple Myeloma–related Bone Disease

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Key Points

  • The use of intravenous bisphosphonates should be considered for all multiple myeloma patients receiving first-line antimyeloma therapy, regardless of the presence of osteolytic bone lesions on conventional radiography.
  • Intravenous bisphosphonates provide greater protection against skeletal-related events and greater survival benefits than oral bisphosphonates.
  • Between 70% and 80% of newly diagnosed multiple myeloma patients have osteolytic lesions, putting them at increased risk for skeletal-related events, such as spinal cord compression, and diminishing their quality of life.

The International Myeloma Working Group (IMWG) has developed clinical practice recommendations for the management of multiple myeloma–related bone disease based on published study data through August 2012. Consensus of the interdisciplinary panel of clinical experts on the plasma-cell cancer was used to propose additional guidelines in situations in which there were insufficient published data. The recommendations are published in the Journal of Clinical Oncology.

The recommendations include the use of bisphosphonates for all multiple myeloma patients receiving first-line therapy, regardless of the presence of osteolytic bones lesions on conventional radiography. The IMWG made this recommendation even though it is unknown whether bisphosphonates offer any advantage to patients with no bone disease as determined by magnetic resonance imaging or positron-emission tomography/computed tomography.

Other Recommendations

The panel also recommended the use of intravenous zoledronic acid and pamidronate in the prevention of skeletal-related events over oral bisphosphonates such as clodronate in newly diagnosed myeloma patients because of their antimyeloma effects and survival benefits. Other recommendations include:

  • Intravenous bisphosphonates should be administered every 3 to 4 weeks during initial therapy. Discontinuation of bisphosphonate therapy may be considered after 1 to 2 years in patients who have achieved complete remission or very good partial response.
  • Patients with active disease should continue to receive zoledronic acid or pamidronate. Treatment should resume after disease relapse if it was discontinued in patients achieving complete or very good partial response.
  • Although bisphosphonates are well tolerated, patients should be made aware of any symptoms suggesting adverse events, including osteonecrosis of the jaw, and physicians should monitor patients for renal toxicity. All myeloma patients treated with bisphosphonates should have creatinine clearance, serum electrolytes, and urinary albumin monitored.
  • Balloon kyphoplasty should be considered in patients with symptomatic vertebral compression fractures.
  • The use of low-dose radiation (up to 30 Gy) can be used as palliative treatment for uncontrolled pain, impending pathologic fracture, or spinal cord compression.

According to the report, osteolytic lesions are found in 70% to 80% of newly diagnosed multiple myeloma patients, putting them at increased risk for skeletal-related events, such as spinal cord compression, requiring surgery or palliative radiotherapy to the bone.

“Skeletal-related events impair survival, undermine quality of life, and increase treatment costs,” said panel members.

For full disclosures of the study authors, visit jco.ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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