Multiple Myeloma Coverage from Every Angle

IMWG Offers Updated Recommendations for Managing Myeloma-Related Bone Disease

By: Kelly M. Hennessey, PhD
Posted: Monday, April 5, 2021

Noopur Raje, MD, of Massachusetts General Hospital Cancer Center, Boston, and colleagues, on behalf of the Bone Working Group of the International Myeloma Working Group (IMWG), analyzed currently available case reports, meta-analyses, and data from clinical studies of patients with multiple myeloma and myeloma-related bone disease. Using established levels of evidence and grade recommendations along with previously published recommendations, they updated the clinical practice recommendations for newly diagnosed patients with myeloma-related bone disease, with the roles of zoledronic acid and denosumab reviewed. Their recommendations were published in The Lancet Oncology.

Bisphosphonates such as zoledronic acid or pamidronic acid, or denosumab are recommended as the standard of care for treating patients with multiple myeloma–related bone diseases. Zoledronic acid is the preferred treatment option for patients who do not have imaging findings of myeloma-related bone disease. For patients with myeloma-related hypercalcemia, zoledronic acid was found to be superior to pamidronic acid. However, for patients with multiple myeloma and renal impairment, the human monoclonal antibody denosumab is the preferred treatment, according to the IMWG update.

The researchers recommended zoledronic acid monthly for at least 12 months; if a very good partial response or better is achieved, the treating physician may consider decreasing the dose frequency to every 3 months, 6 months, or even discontinuation, depending on the osteoporosis recommendations. If a very good partial response is not achieved, zoledronic acid should continue until a very good partial response is achieved. The same duration of treatment is recommended for patients administered pamidronic acid.

“We consider preventive measures to be essential to avoid renal impairment, hypocalcemia, and osteonecrosis of the jaw as a result of bone-targeted agent treatment,” the authors commented. “Cement augmentation, radiotherapy, and surgery should be implemented in specific situations, such as spinal cord compression, pain control, and pathological fractures of weight-bearing bones.”

Disclosure: For full disclosures of the study authors, visit

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