Treatment
Myeloma Patients with Normal Plain Radiograph or Osteopenia in
Bone Mineral Density Measurements
➤ The Expert Panel supports starting intravenous bisphosphonates in multiple
myeloma patients with osteopenia (osteoporosis) but no radiographic
evidence of lytic bone disease.
Patients with Monoclonal Gammopathy of Undetermined Significance
➤ Starting bisphosphonates in patients with monoclonal gammopathy of
undetermined significance is NOT recommended unless osteopenia
(osteoporosis) exists.
Dosing and Selection of BMAs
➤ As a result of increased concerns over renal adverse events, dosing
guidelines for patients with pre-existing renal impairment were added to
the zoledronic acid package insert. The guidelines recommend that patients
with pre-existing mild-to-moderate renal impairment (estimated creatinine
clearance, 30–60 mL/min) should receive a reduced dosage of zoledronic
acid.
• No changes in infusion time or interval are required.
• Zoledronic acid has not been studied in patients with severe renal impairment and is
NOT recommended for use in these patients.
• Recent data comparing denosumab to zoledronic acid has demonstrated fewer adverse
events related to renal toxicity with denosumab, and this may be preferred in patients with
compromised renal function.
➤ Pamidronate 90 mg administered over 4–6 hours is recommended for
patients with extensive bone disease and existing severe renal impairment
(serum creatinine level >3.0 mg/dL [265 µmol/L] or an estimated creatinine
clearance <30 mL/min).
• Although no dosing guidelines are available for patients with pre-existing renal
impairment, the Expert Panel recommends that clinicians consider reducing the initial
pamidronate dose in that setting.
• Infusion times <2 hours with pamidronate or <15 minutes with zoledronic acid should
be avoided.
Duration of Therapy
➤ The Expert Panel suggests that bone-targeted treatment continue for a
period of ≤2 years.
• Less frequent dosing has been evaluated and should be considered in patients with
responsive or stable disease.
• In patients who do not have active myeloma and are on maintenance therapy, the
physician may consider a 3 month interval of bisphosphonate administration.
• There are no data to support a more precise recommendation for duration of
bisphosphonate therapy in this group of patients.
