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Give Bisphosphonates to All Newly Diagnosed Patients with Myeloma, Experts Suggest

Value-Based Care in Myeloma - Multiple Myeloma
Caroline Helwick

Bone complications are common in patients with multiple myeloma. These can significantly diminish the patient’s quality of life and increase the cost of care for patients and for payers. Prevention and early adoption of appropriate intervention can improve the clinical outcomes and reduce cost.

The International Myeloma Working Group (IMWG) has developed clinical practice recommendations for the management of myeloma-related bone disease, based on published trial data through August 2012, as well as consensus among the interdisciplinary panel of clinical experts. The recommendations were published recently (Terpos E, et al. J Clin Oncol. 2013;31:2347-2357).

According to the IMWG panel, skeletal-related events “impair survival, undermine quality of life, and increase treatment costs.”

Guidelines for Using Bone-Protective Agents
The IMWG panel emphasizes the importance of bisphosphonates for all patients receiving front-line antimyeloma therapy, regardless of the presence of osteolytic bone lesions on conventional radiography.

The group acknowledged, however, that it is unknown whether these agents are protective in patients without documented bone disease on magnetic resonance imaging (MRI) or on positron-emission tomography/computed tomography.

The panel also recommended the use of intravenous (IV) zoledronic acid (Zometa; first line) and IV pamidronate disodium (Aredia; second line) in preventing skeletal-related events, rather than oral bisphosphonates, such as clodronate (which is not available in the United States), in newly diagnosed patients, because the IV agents have shown antimyeloma effects and survival benefits.

Duration of Therapy
Bisphosphonates should be given monthly during initial antimyeloma therapy and should be continued in patients who do not achieve remission, according to the new recommendations. After 2 years, patients who have achieved a complete or a very good partial response can discontinue bisphosphonate therapy, but they should resume bisphosphonate therapy on disease relapse. For patients who have only a partial response or less, the use of bisphosphonates should be continued.

Although bisphosphonates are well-tolerated, patients should be alert to symptoms suggestive of toxicity, including osteonecrosis of the jaw. Clinicians should monitor all patients for renal toxicity by measuring creatinine clearance, serum electrolytes, and urinary albumin.

Severe Cases
For patients with symptomatic vertebral compression fractures, balloon kyphoplasty should be considered. The use of low-dose radiation (up to 30 Gy) can be used for palliation of uncontrolled pain, impending pathologic fractures or spinal cord compression, and for vertebral column instability.

Precursor Disease
In patients with smoldering or asymptomatic myeloma, the IMWG notes that both zoledronic acid and pamidronate reduce the risk of developing bone complications, but neither drug slows the progression to overt myeloma. Therefore, the group suggests that patients with low- and intermediate-risk asymptomatic disease who have osteoporosis should receive bisphosphonates at doses that are indicated for osteoporosis. For patients with high-risk smoldering myeloma and bone loss that are suspected of being related to their myeloma (especially if they have MRI findings), clinicians should follow the recommendations for symptomatic myeloma.

A Nurse Practitioner’s Advice
In an interview with Value-Based Care in Myeloma, Beth Faiman, PhDc, MSN, APRN-BC, AOCN, Nurse Practitioner for the Multiple Myeloma Program at the Cleveland Clinic, emphasized the importance of bone protection.

“Bone damage is present in approximately 85% of multiple myeloma patients at any time during diagnosis. As patients are living longer than ever, individuals with bone disease at diagnosis may unfortunately be riddled with pain, decreased mobility, and limited functioning for many years,” she pointed out.

“Interventions such as physical therapy and balloon kyphoplasty, or other surgical intervention, can help somewhat, but rarely will the individual regain baseline functioning,” Ms Faiman said. “Therefore, if bone disease is diagnosed, measures can be taken to strengthen bones and decrease the risk for further skeletal related events.”

She noted that, “the new bone disease guidelines by the IMWG will allow clinicians to do just that—to appropriately diagnose patients with early bone disease and initiate bisphosphonates to decrease the risk of painful skeletal-related events, whether patients have damage to the bone or not.”

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Last modified: May 20, 2015
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