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J Clin Oncol. 2018 Mar 10;36(8):812-818. doi: 10.1200/JCO.2017.76.6402. Epub 2018 Jan 17.

Role of Bone-Modifying Agents in Multiple Myeloma: American Society of Clinical Oncology Clinical Practice Guideline Update.

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Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN.


Purpose To update guideline recommendations on the role of bone-modifying agents in multiple myeloma. Methods An update panel conducted a targeted systematic literature review by searching PubMed and the Cochrane Library for randomized controlled trials, systematic reviews, meta-analyses, clinical practice guidelines, and observational studies. Results Thirty-five relevant studies were identified, and updated evidence supports the current recommendations. Recommendations 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 administration of pamidronate 90 mg over at least 2 hours or zoledronic acid 4 mg over at least 15 minutes every 3 to 4 weeks is recommended. Denosumab 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 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 panel discusses measures regarding osteonecrosis of the jaw. Additional information is available at and .

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