Bone-modifying agent guidelines revised for multiple myeloma
medwireNews: Clinical practice guidelines for the use of bone-modifying agents in patients with multiple myeloma have been updated by the American Society of Clinical Oncology (ASCO).
The ASCO update panel recommends that patients who show lytic bone destruction or spinal compression fractures from osteopenia be treated with intravenous pamidronate 90 mg over at least 2 hours or zoledronic acid 4 mg over at least 15 minutes, every 3–4 weeks.
Bisphosphonate treatment is also recommended for patients with painful osteolytic disease, as well as for those undergoing fracture treatment or radiation, and patients who have osteopenia but no evidence of lytic bone disease. Treatment is not recommended for patients with solitary plasmacytoma , or for those with smoldering or indolent myeloma.
Denosumab provides a noninferior alternative to zoledronic acid with fewer renal toxicity events but should not be stopped abruptly, the update panel writes. Physicians should also consider using a lower dose of pamidronate for patients with pre-existing renal toxicity and avoid use of zoledronic acid in those with severe renal impairment.
Bone-modifying treatments should be used for up 2 years and physicians may consider altering the frequency for patients with responsive or stable disease. Treatment should be reinitiated on skeletal disease relapse.
The guidelines also recommend that patients undergoing bisphosphonate therapy should undergo albuminuria testing every 3–6 months, with further assessment required for unexplained albuminuria.
Finally, the update panel highlights the risk for osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonate therapy or denosumab. Patients undergoing treatment should undergo dental examination before therapy, be treated for oral infection and sites at risk of infection, and avoid invasive dental work where possible.
“While on therapy, patients should maintain excellent oral hygiene and avoid invasive dental procedures, if possible,” the guidance states.
“Continuation of a bone-targeting agent in the setting of ONJ has to be individualized and dependent on a risk–benefit ratio and the severity of bone disease,” the authors add.
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