We are international
Donate
TEXT SIZE   
   back

IMWG Guidelines for the Use of Bisphosphonates in Myeloma
01.27.10

Intravenous bisphosphonate therapy has been amply demonstrated to reduce bone complications of myeloma.   Bisphosphonate (BP) therapy is therefore an important component of supportive care for myeloma patients with boney disease. Adverse events associated with BP are usually mild and consist of fever, renal function impairment, myalgias, and hypocalcemia.  A more serious potential side effect of bisphosphonate therapy that was first identified in 20031 is osteonecrosis of the jaw (ONJ), a debilitating problem that can be associated with significant morbidity.
The following guidelines for the use of bisphosphonate therapy in myeloma are based upon IMWG and Mayo Clinic guidelines2,3 and are intended to provide safe criteria for bisphosphonate use to minimize risk and maximize benefit:

  • Bisphosphonate therapy administered monthly is appropriate for patients with overt myeloma-related lytic bone disease on radiographs and/or MRI and/or PET/CT.
  • Bisphosphonate (BP) use is not recommended in patients with smoldering myeloma.
  • Given the higher rate of ONJ in patients receiving long-term zoledronic acid, pamidronate or clodronate (outside the U.S.) is preferred for longer-term use (> 2 years).
  • Pretreatment comprehensive dental evaluation is important in patients who will receive intravenous BP.  After BP therapy has been initiated, patients should see a dentist at least annually, and elective procedures such as extractions should be attempted only after careful consideration of the risk of ONJ.
  • BP use should not be indefinite or open-ended. 
  • In patients who have achieved a complete or very good partial response and have no active bone disease, BP therapy is not recommended beyond the first year.
  • For patients with less than a very good partial response and/or on-going bone disease, further BP use is recommended; however after two years patients without active bone disease can discontinue BP use.
  • In patients who relapse with new bone disease, BP therapy with pamidronate or clodronate should be reinstituted.   Careful monitoring of dental status and renal function is required with long-term BP use. 
  • Patients who develop ONJ should discontinue BP use.

The following table from the American Association of Oral and Maxillofacial Surgery Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw (approved September 25, 2006) presents their recommendations for staging and treatment strategies:

BRONStaging

Treatment Strategies

At risk category No apparent exposed/necrotic bone in patients who have been treated with either oral or IV bisphosphonates

• No treatment indicated

• Patient education

Stage 1 Exposed/necrotic bone in patients who are asymptomatic and have no evidence of infection

• Antibacterial mouth rinse

• Clinical follow-up on a quarterly basis

• Patient education and review of indications for continued bisphosphonate therapy

Stage 2 Exposed/necrotic bone associated with infection as evidenced by pain and erythema in the region of the exposed bone with or without purulent drainage

• Symptomatic treatment with broad-spectrum oral antibiotics, e.g. penicillin, cephalexin, clindamycin, or 1st generation fluoroquinolone

• Oral antibacterial mouth rinse
• Pain control

• Only superficial debridements to relieve soft tissue irritation

Stage 3 Exposed/necrotic bone in patients with pain, infection, and one or more of the following: pathologic fracture, extra-oral fistula, or osteolysis extending to the inferior border

• Antibacterial mouth rinse

• Antibiotic therapy and pain control

• Surgical debridement/resection for longer term palliation of infection and pain

1 Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic [letter]. J Oral Maxillofac Surg.
2003;61:1115-1117.

2 Durie BGM Mayo Clin Proc. April 2007;82(4):516-522,[letter]
3 Lacy MQ et al. Mayo Clin Proc.  August 2006;81(8):1047-1053

 related videos
 related articles
Osteonecrosis of the...
Use of Bisphosphonat...
IMWG consensus state...
IMWG Guidelines for ...
IMWG Guidelines for ...
IMWG Guidelines for ...
International Myelom...
International Myelom...
A Practical Guide to...
ASCO 2010: A phase I...
ASCO 2010: Bone mark...
ASCO 2010: Elotuzuma...
ASCO 2010: Lenalidom...
ASCO 2010: Mechanism...
ASCO 2010: Modified ...
ASCO 2010: Multiple ...
ASCO 2010: Neurotoxi...
ASCO 2010: Phase I s...
ASCO 2010: Phase Ib ...
ASCO 2010: Results o...
ASCO 2010: Stromal e...
ASCO 2010: Total the...
Clinically relevant ...
Confirmation of the ...
Developing a SNP Cla...
Eliminating the comp...
ESAs not the culprit...
Genetic association ...
Genetic Associations...
Genetic Associations...
Genetic polymorphism...
Genetic Variations A...
Genomic variation in...
IMWG Criteria for th...
Inaugural Summit of ...
International Myelom...
Long-Term Follow-Up ...
Long-Term Follow-Up ...
New Approaches to Tr...
Oncology Nurses Take...
RT-PCR Amplicons in ...
Survival and Years o...
Advocacy Update - Se...
Advocacy Update - Se...
Common Symptoms Of M...

Statement on the pas...

ASCO 2010: A phase II study of a modified pegylated liposomal doxorubicin (PLD), bortezomib, and dexamethasone regimen for patients with previously untreated multiple myeloma (MM).
ASCO 2010: Bone marker assessment as a guide to chronic use of aminobisphosphonates in multiple myeloma.
ASCO 2010: Elotuzumab in combination with bortezomib in patients with relapsed/refractory multiple myeloma: A phase I study.
ASCO 2010: Lenalidomide maintenance after transplantation for myeloma.
ASCO 2010: Mechanism of the antimyeloma activity of PU-H71, a novel purine scaffold HSP90 inhibitor.
ASCO 2010: Modified high-dose melphalan and autologous stem cell transplantation (mHDM/SCT) in the treatment of AL amyloidosis (AL) and/or high-risk myeloma (hM): Analysis of a Southwest Oncology Group trial.
ASCO 2010: Multiple myeloma is characterized by widespread epigenomic alterations with prognostic implications.
ASCO 2010: Phase I study of combined vorinostat (V), lenalidomide (L), and dexamethasone (D) in patients (pts) with relapsed or refractory multiple myeloma (MM).
ASCO 2010: Phase Ib study of oral panobinostat (LBH589) plus lenalidomide (LEN) plus dexamethasone (DEX) in patients (Pts) with relapsed (Rel) or Rel and refractory (Ref) multiple myeloma (MM).
ASCO 2010: Results of an ongoing open-label, phase II study of carfilzomib in patients with relapsed and/or refractory multiple myeloma (R/R MM).
ASCO 2010: Stromal elements and engraftment (ENG) in autologous hematopoietic progenitor cell transplant (autoHCT) for myeloma.
ASCO 2010: Total therapy 3 (TT3) for multiple myeloma (MM): Contributions to survival outcomes of dosing of maintenance components dexamethasone (D), thalidomide (T) and bortezomib (V).
What is multiple myeloma?
Dr. Morie Gertz of the Mayo Clinic in Rochester, MN.
Osteonecrosis of the Jaw and Biphosphonates
Use of Bisphosphonates in Multiple Myeloma: IMGW Response to Mayo Clinic Consensus Statement
IMWG consensus statement on the role of vertebral augmentation in multiple myeloma
IMWG Guidelines for Facilities and Services for the Management of Myeloma Patients
IMWG Guidelines for the Management of Multiple Myeloma Patients Ineligible for Standard High-Dose Chemotherapy with Autologous Stem Cell Transplantation
IMWG Guidelines for the Prevention of Thalidomide- and Lenalidomide-Associated Thrombosis in Myeloma
International Myeloma Working Group (IMWG) Uniform Response Criteria for Multiple Myeloma
International Myeloma Working Group Guidelines on Imaging Techniques in the Diagnosis and Monitoring of Multiple Myeloma1
A Practical Guide to Achieving and Maintaining the Best Response to Lenalidomide in Multiple Myeloma: Roundtable Proceedings
ASCO 2010: A phase II study of a modified pegylated liposomal doxorubicin (PLD), bortezomib, and dexamethasone regimen for patients with previously untreated multiple myeloma (MM).
ASCO 2010: Bone marker assessment as a guide to chronic use of aminobisphosphonates in multiple myeloma.
ASCO 2010: Elotuzumab in combination with bortezomib in patients with relapsed/refractory multiple myeloma: A phase I study.
ASCO 2010: Lenalidomide maintenance after transplantation for myeloma.
ASCO 2010: Mechanism of the antimyeloma activity of PU-H71, a novel purine scaffold HSP90 inhibitor.
ASCO 2010: Modified high-dose melphalan and autologous stem cell transplantation (mHDM/SCT) in the treatment of AL amyloidosis (AL) and/or high-risk myeloma (hM): Analysis of a Southwest Oncology Group trial.
ASCO 2010: Multiple myeloma is characterized by widespread epigenomic alterations with prognostic implications.
ASCO 2010: Neurotoxic and peripheral neuropathic effects in preclinical and clinical studies of carfilzomib (CFZ), a novel proteasome inhibitor (PI).
ASCO 2010: Phase I study of combined vorinostat (V), lenalidomide (L), and dexamethasone (D) in patients (pts) with relapsed or refractory multiple myeloma (MM).
ASCO 2010: Phase Ib study of oral panobinostat (LBH589) plus lenalidomide (LEN) plus dexamethasone (DEX) in patients (Pts) with relapsed (Rel) or Rel and refractory (Ref) multiple myeloma (MM).
ASCO 2010: Results of an ongoing open-label, phase II study of carfilzomib in patients with relapsed and/or refractory multiple myeloma (R/R MM).
ASCO 2010: Stromal elements and engraftment (ENG) in autologous hematopoietic progenitor cell transplant (autoHCT) for myeloma.
ASCO 2010: Total therapy 3 (TT3) for multiple myeloma (MM): Contributions to survival outcomes of dosing of maintenance components dexamethasone (D), thalidomide (T) and bortezomib (V).
Clinically relevant end points and new drug approvals for myeloma
Confirmation of the utility of the International Staging System and identification of a unique pattern of disease in Brazilian patients with multiple myeloma
Developing a SNP Classifier for Predicting Peripheral Neuropathy by Bortezomib in Multiple Myeloma Patients
Eliminating the complete response penalty from myeloma response criteria
ESAs not the culprit: More studies required
Genetic association with thalidomide mediated venous thrombotic events in myeloma indentified using targeted genotyping
Genetic Associations with Bortezomib Mediated Neuropathy in Multiple Myeloma
Genetic Associations with Therapy Response in the HOVON-65/GMMG-HD4 Trial in Patients with Multiple Myeloma
Genetic polymorphisms of EPHX1, Gsk3 beta, TNFSF8 and myeloma cell DKK-1 expression linked to bone disease in myeloma
Genetic Variations Associated with Overall and Progression-Free Survival in Multiple Myeloma Patients Treated with Thalidomide Combinations
Genomic variation in myeloma: design, content, and initial application of the Bank On A Cure SNP Panel to detect associations with progression-free survival
IMWG Criteria for the Diagnosis of Myeloma and Guidelines for the Diagnostic Work-Up of Myeloma
Inaugural Summit of the International Myeloma Working Group Lays the Groundwork for a Course Toward a Cure.
International Myeloma Working Group at ASH 2009
Long-Term Follow-Up of Autotransplantation Trials for Multiple Myeloma: Update of Protocols Conducted by the Intergroupe Francophone du Myelome, Southwest Oncology Group, and University of Arkansas for Medical Sciences
Long-Term Follow-Up of Autotransplantation Trials for Multiple Myeloma: Update of Protocols Conducted by the Intergroupe Francophone du Myelome, Southwest Oncology Group, and University of Arkansas for Medical Sciences
New Approaches to Treatment for Multiple Myeloma: Durable Remission and Quality of Life as Primary Goals
Oncology Nurses Take the Lead in Providing Novel Therapy Guidelines for Multiple Myeloma
RT-PCR Amplicons in the Plasma of Multiple Myeloma Patients
Survival and Years of Life Lost in Different Age Cohorts of Patients With Multiple Myeloma
Advocacy Update - September 1, 2009
Advocacy Update - September 15, 2009
Common Symptoms Of Multiple Myeloma
WHAT IS MULTIPLE MYELOMA
Statement on the passing of Senator Kennedy