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Updated Recommendations on the Treatment of Multiple Myeloma–Related Bone Disease From the Bone Working Group of the International Myeloma Working Group


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In a policy review reported in The Lancet Oncology, Terpos et al presented updated recommendations from the Bone Working Group of the International Myeloma Working Group on the treatment of multiple myeloma–related bone disease.

The recommendations cover: bisphosphonate use/dosing and management of adverse events; denosumab use/dosing and management of adverse events; and use of other approaches such as cement augmentation, radiotherapy, and surgery.

Select recommendations are reproduced/summarized below.

Select Recommendations

  • Bisphosphonates or denosumab should be considered as the standard of care for the treatment of multiple myeloma–related bone disease. The choice of one bone-targeted agent over another should include consideration of multiple factors, including cost, convenience, patient preference, and toxicity profile.
  • Bisphosphonates (ie, zoledronic acid or pamidronic acid) should be administered to all patients with active multiple myeloma, regardless of the presence or absence (for zoledronic acid only) of multiple myeloma–related bone disease on imaging studies.
  • Zoledronic acid is the preferred bone-targeted agent for patients with newly diagnosed multiple myeloma, with or without multiple myeloma–related bone disease. Once patients achieve a very good partial response or better and have received monthly zoledronic acid for at least 12 months, decreasing the frequency of or discontinuing zoledronic acid treatment can be considered.
  • Denosumab can also be considered for the treatment of multiple myeloma–related bone disease and should be the preferred treatment option for patients with renal impairment. Denosumab may prolong progression-free survival in patients with newly diagnosed multiple myeloma who have multiple myeloma–related bone disease and who are eligible for autologous stem cell transplantation. Denosumab discontinuation is challenging due to the rebound effect associated with discontinuation. If denosumab is discontinued, patients should receive a single dose of zoledronic acid to prevent rebound effects at least 6 months after the last dose of denosumab.
  • Economic models indicate that denosumab is a cost-effective treatment both in the United States and Europe vs zoledronic acid. However, interpretation of the studies is limited by various factors, including cost estimates being derived from multiple sources that varied by patient population, country, and other parameters.
  • Preventive measures are essential to avoid renal impairment, hypocalcemia, and osteonecrosis of the jaw as a result of bone-targeted agent treatment.
  • Cement augmentation is effective for painful vertebral compression fractures.
  • Radiotherapy is recommended for uncontrolled pain, impeding or symptomatic spinal cord compression, or pathologic fractures.
  • Surgery should be performed for the prevention and restoration of long-bone pathologic fractures, vertebral column instability, and spinal cord compression with bone fragments within the spinal route.

Evangelos Terpos, MD, of the Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, is the corresponding author for The Lancet Oncology article.

Disclosure: For full disclosures of the study authors, visit thelancet.com.


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