Osteoclast inhibitors for multiple myeloma

CT: computed tomography; MRI: magnetic resonance imaging; PET/CT: positron emission tomography/computed tomography; MM: multiple myeloma.
* Advise patients to take daily supplemental calcium (1000 mg elemental daily) and vitamin D (at least 400 units daily).
¶ We do not offer an osteoclast inhibitor to patients with MM who have no bone lesions identified on cross-sectional imaging (CT, MRI, PET/CT) and have normal bone densitometry, as it is not known whether such patients benefit from this therapy. Other experts offer osteoclast inhibitors to all patients with symptomatic MM, including those without detectable bone involvement.
Δ We suggest treatment be given monthly for a period of at least two years. After two years, we reassess tolerability and suggest continued monthly administration in all patients, as long as it is well tolerated. It is reasonable to discontinue the osteoclast inhibitor after two years in patients with responsive or stable MM with plans to restart the osteoclast inhibitor at MM progression.
◊ Acceptable alternatives include pamidronate (90 mg intravenously over 2 hours every 4 weeks) and denosumab (120 mg subcutaneously every 4 weeks).
§ For most patients with renal impairment, we suggest denosumab rather than a bisphosphonate. Patients with impaired renal function from myeloma-related causes who normalize kidney function with effective anti-myeloma therapy can switch from denosumab to zoledronic acid. Reduced dose and/or slower infusion rate bisphosphonate is an alternative for those without access to denosumab.