Role of Bone-Modifying Agents in Multiple Myeloma: ASCO Clinical Practice Guideline Update

As reported in the Journal of Clinical Oncology by Kenneth Anderson, MD, of Dana-Farber Cancer Institute, and colleagues, ASCO has issued a clinical practice guideline update on the role of bone-modifying agents in multiple myeloma. The update was informed by an expert panel systematic literature review including 35 relevant studies. The expert panel was co-chaired by Dr. Anderson and Robert A. Kyle, MD, of Mayo Clinic, Rochester. Key recommendations are summarized here:

  • For patients with active symptomatic multiple myeloma that requires systemic therapy with or without evidence of lytic destruction of bone or compression fracture of the spine from osteopenia on plain radiograph(s) or other imaging studies, intravenous pamidronate at 90 mg over at least 2 hours or zoledronic acid at 4 mg over at least 15 minutes every 3 to 4 weeks is recommended.
  • Denosumab (Xgeva) has shown to be noninferior to zoledronic acid for the prevention of skeletal-related events and provides an alternative. Fewer adverse events related to renal toxicity have been noted with denosumab compared with zoledronic acid and denosumab may be preferred in this setting.
  • The update panel recommends that clinicians consider reducing the initial pamidronate dose in patients with preexisting renal impairment. Zoledronic acid has not been studied in patients with severe renal impairment and is not recommended in this setting.
  • The update panel suggests that bone-modifying treatment continue for up to 2 years. Less frequent dosing has been evaluated and should be considered in patients with responsive or stable disease. Continuous use is at the discretion of the treating physician and the risk of ongoing skeletal morbidity. Retreatment should be initiated at the time of disease relapse.
  • The update discusses factors in reducing the risk of osteonecrosis of the jaw and in treatment of patients developing osteonecrosis of the jaw.

Additional information is available at and

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.




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