Treatment of multiple myeloma-related bone disease: recommendations from the Bone Working Group of the International Myeloma Working Group
- Study type
- Clinical guideline
- Study name
- IMWG Bone Working Group 2021
- Design
- Policy review and clinical guideline with recommendations graded by the GRADE method
- Source
- The Lancet Oncology · 2021
In plain words
In many people with multiple myeloma the bones become weak, which can cause pain or fractures. This guideline says that the drug zoledronic acid is usually the first choice to protect the bones, and that denosumab can also be an option, especially for patients with kidney problems. For pain that is not controlled, pressure on the spinal cord or fractures, radiotherapy is used, and in some cases cement treatment of the spinal bones or surgery. The final decision should be made by your own doctor.
Key guideline recommendations
- GRADE graded (exact level in the full text)
Zoledronic acid is recommended as the preferred bone-targeted agent for patients with newly diagnosed multiple myeloma, with or without myeloma-related bone disease.
- GRADE graded (exact level in the full text)
After achieving a very good partial response or better and receiving at least 12 months of monthly zoledronic acid, the treating physician may consider reducing the frequency of zoledronic acid or stopping it.
- GRADE graded (exact level in the full text)
Denosumab can also be considered for the treatment of multiple myeloma-related bone disease, especially in patients with renal impairment. Denosumab may prolong progression-free survival in newly diagnosed patients eligible for autologous stem cell transplantation who have myeloma-related bone disease. Stopping denosumab is difficult because of the rebound effect.
- GRADE graded (exact level in the full text)
Cement augmentation is effective for painful vertebral compression fractures.
- GRADE graded (exact level in the full text)
Radiotherapy is recommended for uncontrolled pain, impending or symptomatic spinal cord compression, or pathological fractures.
- GRADE graded (exact level in the full text)
Surgery should be used to prevent and repair pathological fractures of long bones, spinal instability and spinal cord compression with bony fragments in the spinal canal.
Study population
Patients with newly diagnosed multiple myeloma, with or without myeloma-related bone disease; further details on the target population are in the full text.
Endpoints
This paper is a clinical guideline and has no trial endpoints. Recommendations were graded after a review of the existing literature using the GRADE method (Grading of Recommendations, Assessment, Development and Evaluations).
Safety and side effects
The abstract specifically notes that stopping denosumab is difficult because of a rebound effect. Other safety details are in the full text.
Clinical significance and place in guidelines
This guideline updates the International Myeloma Working Group recommendations for managing myeloma-related bone disease and names zoledronic acid as the preferred bone-targeted agent. Denosumab is an option, especially in renal impairment. Radiotherapy and surgery also have a defined role for painful vertebral fractures. Whether these recommendations have been adopted in other national and international guidelines should be checked separately.
Limitations
This paper is a policy review based on expert opinion and the existing literature, not a primary trial. Details of the quality of evidence and the strength of each recommendation are not given in the abstract and should be checked in the full text.
This summary was prepared by the editorial team from the published paper; the original paper is the final reference. Read the original abstract on PubMed.