May 13, 2018
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ASCO updates guideline on use of bisphosphonates for multiple myeloma

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An updated ASCO clinical practice guideline defines when to appropriately initiate treatment with bisphosphonates among patients with multiple myeloma.

To update the guideline — last updated in 2007 — the panel conducted a systematic review of randomized controlled clinical trials, systematic reviews, meta-analyses, clinical practice guidelines and observational studies published between January 2007 and July 2017. Thirty-five studies provided the evidence for the recommendations.

The guidelines state patients with active symptomatic multiple myeloma, with or without evidence of lytic destruction of bone or compression fracture of the spine from osteopenia receive 90 mg IV pamidronate over a minimum 2 hours or 4 mg IV zoledronic acid over a minimum 15 minutes every 3 to 4 weeks. Patients administered pamidronate or zoledronic acid should be evaluated every 3 to 6 months for albuminuria through spot urine sample.

The authors also noted:

  • Initial pamidronate dose should be reduced among patients with preexisting renal impairment;
  • Zoledronic acid is not recommended for patients with severe renal impairment, and with patients with preexisting mild-to-moderate renal impairment should a receive lower dose of zoledronic acid;
  • Denosumab (Xgeva/Prolia, Amgen) can serve as an alternative to zoledronic acid;
  • Treatment should continue for up to 2 years;
  • Dosing may be less frequent among patients with responsive or stable disease; and
  • Retreatment should be initiated at relapse.

Physicians should use their discretion regarding continuous bisphosphonate use, considering the risk for ongoing skeletal morbidity

The panel also noted bisphosphonates are not recommended for patients with solitary plasmacytoma, asymptomatic or indolent disease, nor for patients with monoclonal gammopathy with undetermined significance unless osteopenia occurs.

The research panel further suggested patients should undergo a dental examination before initiation of bone-modifying therapy due to risk for osteonecrosis of the jaw after treatment with potent bisphosphonates, including pamidronate and zoledronic acid.

“While on therapy, patients should maintain excellent oral hygiene and avoid invasive dental procedures if possible,” the panel wrote. “Continuation of a bone-targeting agent in the setting of osteonecrosis of the jaw has to be individualized and dependent on a risk-benefit ratio and the severity of bone disease.” – by Melinda Stevens

Disclosures: Please see the study for a list of all authors’ relevant financial disclosures.