New Guidelines for Multiple Myeloma-Related Bone Disease

New guidelines for the management of bone disease in all patients with multiple myeloma, issued by the International Myeloma Working Group, were published online May 20 in the Journal of Clinical Oncology.

“Bisphosphonates (zoledronic acid or pamidronate) should be considered in all myeloma patients receiving frontline antimyeloma therapy, regardless of the presence of osteolytic bone lesions on conventional radiography,” said lead author Evangelos Terpos, MD, PhD, from the Department of Clinical Therapeutics at the University of Athens School of Medicine and the Alexandra General Hospital in Greece.

“Previously, the recommendation was only for patients who had myeloma-related bone disease,” Dr. Terpos told Medscape Medical News. However, it is not clear whether bisphosphonates offer any advantage for patients with no evidence of bone disease on magnetic resonance imaging (MRI) or positron emission tomography/computed tomography (PET/CT), he explained.

Despite the introduction of novel agents that have led to improved survival, multiple myeloma is still an incurable plasma cell malignancy. At diagnosis, 70% to 80% of patients have osteolytic lesions, which increase the risk for skeletal-related events (pathologic fractures, spinal cord compression, or surgery or palliative radiotherapy to bone).

“I believe that the widespread implementation of these guidelines will help in the management of patients with myeloma and prevent skeletal-related events, improve quality of life, and reduce the cost of treatment,” Dr. Terpos said.

The International Myeloma Working Group convened an interdisciplinary panel of clinical experts to develop practice guidelines for the management of multiple myeloma–related bone disease, after reviewing data published up to August 2012. Panel members assigned and approved levels of evidence and grades of recommendations. For situations lacking sufficient published evidence, the panel relied on expert consensus.

In these guidelines, the previous recommendations of various organizations for the use of bisphosphonates in patients with multiple myeloma have been updated.

“Zoledronic acid is preferred over oral clodronate in newly diagnosed myeloma patients because of its potential antimyeloma effects and survival benefits. Clodronate is currently not recommended, with specific exceptions,” Dr. Terpos said.

Previous recommendations have supported bisphosphonate therapy for 2 years. “We suggest that zoledronic acid or pamidronate be continued in patients with active disease and, if discontinued in patients in complete remission or very good partial remission after antimyeloma therapy, be resumed after disease relapse.”

“Zoledronic acid improves overall survival and reduces skeletal-related events better than clodronate in patients who received treatment for more than 2 years. Therefore, it should be given until disease progression in patients not in complete remission or very good partial remission and continued at relapse (grade B),” Dr. Terpos reported. “There is not similar evidence for pamidronate, but it can be continued in patients with active disease at the physician’s discretion (grade D), and should be resumed after disease relapse (grade D).”

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