The International Osteoporosis Foundation (IOF) Committee of Scientific Advisors (CSA) Bone and Cancer Working Group has released a position statement on bone fragility in patients with monoclonal gammopathy of undetermined significance (MGUS).
The new statement provides guidance on how to evaluate and manage bone fragility in patients with MGUS, considering the higher risk of fracture in these patients.
The authors gathered and reviewed available evidence on epidemiological fracture data, bone mineral density, bone microarchitecture, bone turnover marker, and bone histomorphometry data in patients with MGUS to determine that these patients have an elevated risk of fractures, although data was limited. Particularly, the Working Group determined that patients with MGUS have about twice the risk of vertebral fractures and 1.5-fold higher risk of hip fractures due to osteoporotic clinical risk factors, low bone mass, MGUS-related comorbidities, and MGUS bone impacts (including senesence of plasma cells).
They used these findings to create recommendations for the evaluation of bone fragility and fracture risk in patients with MGUS and a risk-adapted clinical practice algorithm for bone fragility management to assist general practitioners, internists, geriatricians, endocrinologists, rheumatologists, hematologists, gynecologists, advanced practice nurses, and other clinicians who treat patients with MGUS.
“MGUS is usually viewed through a hematological lens, with attention focused on its progression to myeloma. Yet evidence shows that these patients also face a substantially higher risk of fracture, particularly of the spine,” said lead corresponding author Cyrille B. Confavreux, MD, PhD, Professor and Chair/Head of the Department of Rheumatology at the Cancer Institute of Hospices Civils de Lyon and Université Claude Bernard Lyon 1, France. “This position statement gives clinicians a pragmatic, risk-adapted pathway: screen for MGUS when investigating a fragility fracture, undertake a comprehensive bone evaluation when clinical MGUS is diagnosed, and treat patients at risk with antiresorptive agents at osteoporosis rather than oncology doses."
The position statement recommends that patients with a new diagnosis of clinical MGUS should undergo a comprehensive bone evaluation, which should include assessment of fracture risk factors, comorbidities, bone turnover markers, and a bone density test at the hip and spine. These patients should also undergo annual follow-up and a bone reassessment after 3 years if they do not experience any incident fragility fractures in that time.
The guidance also names bisphosphonates as the preferred treatment option.
“Although patients with MGUS are often supported by several specialists, their bone health can still be overlooked. By recognizing MGUS as a cause of secondary osteoporosis, clinicians can identify patients at high risk earlier and offer treatment before a fracture occurs. While the evidence base will continue to evolve, this guidance can be implemented in clinical practice today,” said Eugene McCloskey, MD, Professor in Adult Bone Diseases, Mellanby Centre for Musculoskeletal Research, University of Sheffield, and Chair of the IOF CSA.
The guidance also recommends that adult patients with a fragility fracture should be screened for MGUS using serum protein electrophoresis and serum free light chain testing.
DISCLOSURES: The following authors declare the following conflicts of interests: Research grants: PH (Stada), PE (Amgen, Alexion, Sanofi), JJB (UCB) and CC (Amgen, MSD avenir). Conferences: PH (Amgen, Celltrion, Fresenius, Gedeon Richter, Hexal, Sandoz, Stada, Theramex, UCB.), RDB (Abbott Labs, Abbvie, Amgen, AstraZeneca, Bio-Rad Labs,Chugai, Doctorpedia, Eli Lilly, Glaxo, Illumina, JangoBio, Johnson & Johnson, Merck, Novartis, Novo Nordisk, Nutrien, Procter & Gamble, ROMTech, Sandoz, Sanofi, Siemens, Teva, UCB). PE (Amgen, Kyowa-Kirin, Alexion), JJB (UCB, Sandoz), TJV (Abbott, Aspen, Pharmaforce, Adcock, Ingram, Cipla Medpro), and CC (Abvie, AstraZeneca, Celltrion, Fresenius, Sandoz, UCB, Sandoz). The following authors AEM, CC, DK, RB, MB, JH, JF, and RR declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work in this paper.
