ASCO Updates Recommendations for Bone-Modifying Agents in Multiple Myeloma


The American Society of Clinical Oncology (ASCO) released a clinical practice guideline update on the role of bone-modifying agents in patients with active symptomatic multiple myeloma, published in the Journal of Clinical Oncology (online January 17, 2018; doi:10.1200/JCO.2017.76.6402).

An updated panel led by Kenneth Anderson, MD, PhD, Dana-Farber Cancer Institute (Boston, MA), conducted a targeted systematic literature review. Researchers utilized PubMed and the Cochrane Library to identify randomized controlled trials, systematic reviews, meta-analyses, clinical practice guidelines, and observational studies related to bone-modifying agents in multiple myeloma.

A total of 35 relevant studies were chosen to form the basis of these updated recommendations.

In patients with active symptomatic multiple myeloma requiring systemic therapy regardless of evidence of lytic bone destruction or spine compression fracture from osteopenia on plain radiograph or other imaging studies, intravenous administration of pamidronate (90 mg over at least 2 hours) or zoledronic acid (4 mg over at least 15 minutes every 3-4 weeks) is recommended.

Denosumab is cited as being non-inferior to zoledronic acid for the prevention of skeletal-related events. Additionally, denosumab is linked to fewer renal adverse events compared with zoledronic acid, which may make it preferable in this setting.


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The panel recommends that clinicians consider reducing the initial pamidronate dose in patients with pre-existing renal impairment. Contrarily, zoledronic acid is not recommended for patients with pre-existing renal impairment due to a lack of available evidence.

The panel suggests that bone-modifying treatment should continue for up to 2 years. Less frequent dosing has been evaluated and should be offered in patients with responsive or stable disease. Continuous use thereafter 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 panel recommends.—Zachary Bessette