ÎAlthough most cases of ONJ have occurred in patients treated with IV bisphosphonates and BMAs who underwent an invasive dental procedure, cases have occurred spontaneously and have been reported in patients treated with other BMAs, including oral bisphosphonates and direct osteoclast inhibitors.
Optimal Duration
ÎThe Panel suggests that, once initiated, BMAs be continued until there is evidence of substantial decline in a patient's general performance status.
ÎThe Panel stresses that clinical judgment must guide what constitutes a substantial decline.
ÎThere is no evidence addressing the consequences of stopping BMAs after one or more adverse skeletal-related events.
Optimal Intervals Between Dosing
ÎFor patients with breast cancer who have evidence of bone destruction on plain radiographs, denosumab 120 mg subcutaneously every 4 weeks, IV pamidronate 90 mg delivered over 2 hours or IV zoledronic acid 4 mg over 15 minutes every 3 to 4 weeks is recommended.
ÎThere is no evidence addressing increasing the interval between doses. Role of BMAs in Pain Control
ÎApply current standards of care for cancer bone pain management at the onset of pain, in concert with the initiation of BMA therapy. Good clinical practice requires this.
ÎThe standard of care for bone pain management includes the use of nonsteroidal anti-inflammatory agents, opioid and nonopioid analgesics, corticosteroids, adjuvant agents, interventional procedures, systemic radiopharmaceuticals, local radiation therapy, and surgery.
ÎBMAs are an adjunctive therapy for cancer-related bone pain control and are NOT recommended as first-line treatment for cancer-related pain.
ÎIV pamidronate or zoledronic acid may be of benefit for patients with pain caused by bone metastases and may contribute to pain relief when used concurrently with analgesic therapy, systemic chemotherapy, radiation therapy, and/or hormonal therapy.
ÎBMAs have been associated with a modest pain control benefit in controlled trials.
The Role of Biochemical Markers
ÎUse of biochemical markers of bone metabolism to monitor BMA use is NOT recommended for routine care.
> Note: For each of the recommendations, clinical judgment should also take into consideration the patient's general performance status, patient preferences, and overall prognosis.
