Table 1.

Summary of Bisphosphonate Guidelines in Multiple Myeloma

Factor	NCCN14	ESMO17	ASCO15	Mayo16	IMWG Reply to Mayo18	EMN19
Patient population	Active or all other stages of myeloma	Stage III or relapsed disease receiving conventional-dose chemotherapy	Lytic disease (lytic destruction of bone or compression fracture of spine from osteopenia) on plain radiographs or imaging studies	All patients with lytic bone disease on plain radiographs	In addition to radiographs, other imaging studies (MRI, CT, PET/CT)	All patients with lytic bone disease on plain radiographs
	Adjunctive therapy for bone disease		Patients with osteopenia but no evidence of lytic bone disease based on normal plain radiograph or BMD measurements	Patients with osteopenia or osteoporosis on BMD studies		Patients with osteopenia or osteoporosis on BMD studies
						Patients receiving chemotherapy
Administration	IV	Oral or IV	Oral or IV	IV	Oral or IV	Oral or IV
PAM IV infusion time	N/A	N/A	At least 2 hours	At least 2 hours	N/A	2 to 4 hours
Duration/frequency	N/A	Long term	Monthly for 2 years	Monthly for 2 years	2 years	2 years, if not in CR
				After 2 years: Discontinue if CR or stable plateau phase	After 1 year: Discontinue if CR or VGPR and no active bone disease	After 1 year: Continue at physician discretion, if CR
				Decrease to every 3 months if active disease	Continue if < VGPR and/or ongoing active bone disease	Restart on relapse
					After 2 years: Discontinue if no active bone disease
					If active bone disease, continue at own discretion
Monitoring	Chronic users should be monitored for renal function and ONJ	N/A	Monitor serum creatinine before each PAM or ZOL dose	N/A	N/A	Monitor patients for compromised renal function (creatinine clearance)
	Smoldering/stage I MM: Use BP in trial with yearly bone surveys		Regularly monitor serum calcium, electrolytes, phosphate, magnesium, hematocrit/hemoglobin			Patients with compromised renal function should have creatinine clearance rates, serum electrolytes, and albuminuria monitored
Choice	PAM or ZOL	N/A	ZOL, PAM, or CLO (non–United States)	PAM (favorable) or ZOL	PAM, ZOL, or CLO	ZOL, PAM, or CLO (where indicated)

Abbreviations: ASCO, American Society of Clinical Oncology; BMD, bone mineral density; BP, bisphosphonate; CLO, clodronate; CR, complete response; CT, computed tomography; EMN, European Myeloma Network; ESMO, European Society for Medical Oncology; IMWG, International Myeloma Working Group; IV, intravenous; MM, multiple myeloma; MRI, magnetic resonance imaging; N/A, not applicable; NCCN, National Comprehensive Cancer Network; ONJ, osteonecrosis of the jaw; PAM, pamidronate; PET, positron emission tomography; VGPR, very good partial response; ZOL, zoledronic acid.

Adapted with permission.¹⁹