Key Points
➤ The definition of active multiple myeloma requiring therapy has been
revised. HyperCalcemia, Renal dysfunction, Anemia or Bone disease
(CRAB) remain indications for treatment.
➤ In the absence of these CRAB features, patients who have >60% bone
marrow plasma cells, involved free light chain >100 mg/L with kappa/
lambda ratio >100 fold, or more than one site of bone disease on MRI or on
PET CT scanning are now recommended for treatment.
➤ Any patient who is on treatment for active multiple myeloma should
receive bisphosphonate therapy.
➤ Clodronate is approved worldwide, except in the United States, for either
oral or intravenous administration. However, the recent MRC IX RCT
shows that intravenous zoledronic acid is superior in avoiding skeletal
complications.
Treatment
Indications to initiate a BMA
Patients with Lytic Disease on Plain Radiographs or Other
Imaging Studies
➤ For multiple myeloma patients who have, on plain radiograph(s) or other
imaging studies (MRI or CT scan), lytic destruction of bone or compression
fracture of the spine from osteopenia, intravenous pamidronate 90 mg
delivered over ≥2 hours or zoledronic acid 4 mg delivered over ≥15 minutes
every 3–4 weeks is recommended.
• Alternative treatment includes the use of denosumab, a monoclonal antibody targeting
RANKL.
Patients with Osteopenia in the Absence of Lytic Disease
➤ Starting bisphosphonates in patients with solitary plasmacytoma or
smoldering (asymptomatic) or indolent myeloma is NOT recommended.
Adjunct to Pain Control in Patients With Pain Resulting from Osteolytic
Disease and Those Receiving Other Interventions for Fractures or
Impending Fractures
➤ Intravenous pamidronate or zoledronic acid is recommended for patients
with pain as a result of osteolytic disease and as an adjunctive treatment for
patients receiving radiation therapy, analgesics, or surgical intervention to
stabilize fractures or impending fractures.
• Denosumab is an additional option.
