ASCO Guideline: Bisphosphonates in Myeloma

ALEXANDRIA, Virginia—The American Society of Clinical Oncology (ASCO) has developed updated guideline recommendations on the use of bisphosphonates in patients with multiple myeloma. The key recommendations address three areas: therapy duration, dosage, and monitoring; osteonecrosis of the jaw; and several previous recommendations. There are two intravenous bisphosphonates that are FDA approved for treating bone loss from multiple myeloma: pamidronate (Aredia) and zoledronic acid (Zometa).

Duration, Dosage, Monitoring

The guideline recommends that bisphosphonates be given to patients monthly for 2 years. At 2 years, the physician should consider stopping the use of bisphosphonates if the patient has responded to therapy. Physicians should re-start bisphosphonate therapy if a patient's myeloma returns and new bone problems develop.

People with myeloma who experience bone loss or fracture of the spine from osteopenia should receive either 90 mg of pamidronate over 2 hours or 4 mg of zoledronic acid over at least 15 minutes, every 3 to 4 weeks.

Monitoring for albuminuria is recommended in myeloma patients receiving bisphosphonate therapy every 3 to 5 months. The labeling of the two agents also prescribes monitoring levels of creatinine before using either drug.

Zoledronic acid is not recommended for patients with existing kidney problems and extensive bone disease. For these patients, the guideline recommends a longer infusion of 4 to 5 hours of pamidronate.

The guideline also recommends lowering the pamidronate dose in myeloma patients with preexisting mild-to-moderate kidney disease. (The zoledronic acid labeling also recommends lowering the dose for these patients.)

To lessen the risk of patients developing osteonecrosis of the jaw while on bisphosphonates, the guideline recommends that all myeloma patients receive a comprehensive dental examination and appropriate preventive dentistry prior to starting bisphosphonate therapy. While on bisphosphonates, patients should maintain excellent oral hygiene and avoid invasive dental procedures.

The guideline update does not recommend use of bisphophonates for myeloma patients with one bone tumor (solitary plasmacytoma); a slower growing form of myeloma (smoldering or indolent myeloma); or conditions of abnormal plasma cells that are not myeloma but may eventually develop into myeloma (monoclonal gammopathy of undetermined significance). Additionally, the guideline does not suggest use of biochemical markers to monitor bisphosphonate treatment for routine care of myeloma patients.

The guideline will be published in the June 10 issue of the Journal of Clinical Oncology. For a copy of the guideline, visit www.asco.org/guidelines.