New Guidelines Issued in the Treatment of Multiple Myeloma-Related Bone Disease 

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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 were recently published in the Journal of Clinical Oncology (JCO).1

IMWG Recommendations

Included in the recommendations is the use of bisphosphonates for all multiple myeloma patients receiving front-line therapy, regardless of the presence of osteolytic bones lesions on conventional radiography. The IMWG made the 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.

The panel also recommended the use of intravenous zoledronic acid (Zometa) and pamidronate  (Aredia) in the prevention of skeletal-related events over oral bisphosphonates, such as clodronate (Bonefos), 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 zoldronic acid or pamidronate. and the 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 (CrC1), 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, and vertebral column instability.

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. ■

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1. Terpos E, Morgan G, Dimopoulos MA, et al: International Myeloma Working Group Recommendations for the Treatment of Multiple Myeloma-related Bone Disease. J Clin Oncol 31(18):2347-2357, 2013.