Table 1.

Bisphosphonate Guidelines in Multiple Myeloma

	ASCO⁶³	NCCN⁶⁴	Mayo⁶⁵	EMN⁶⁶

Indications	MM with lytic lesion or osteopenia or osteoporosis Not indicated in SMM or MGUS	MM with lytic lesion or osteopenia or osteoporosis Not indicated in SMM or MGUS	MM with lytic lesion or osteopenia or osteoporosis Not indicated in SMM or MGUS	MM with lytic lesion or osteopenia or osteoporosis Not indicated in SMM or MGUS
Duration	2 years, stop if stable disease/responsive disease. Continuing beyond 2 years at discretion of treating physician. Restart at relapse, no guidelines on duration or frequency	N/A	Monthly x2 years then discontinue if in remission or stable/plateau phase. If MM still active, recommend continuing but decrease frequency to every 3 months.	Recommend 2 years of therapy by most of panel. Some on panel prefer to continue beyond 2 years at reduced dose or frequency. Resume on relapse, no recommendation on duration or frequency in this setting.
Surveillance Renal	Creatinine with each dose.	N/A	N/A	Monitor creatinine in all patients. Moniter CrCL, electrolytes and U/A in patient with CKD.
ONJ	Comprehensive dental exam and preventive dentistry prior to starting. While on therapy, maintain good oral hygiene and avoid invasive procedures if possible.	N/A	Comprehensive exam before initiating. Complete required invasive procedures prior to starting. See dentist annually. Manage new dental procedures conservatively. See oral/ maxillofacial surgeon if surgery required.	Clinical dental exam prior to treatment. Treat infections. Complete required dental procedure prior to starting therapy. Dental exam yearly. Avoid elective procedures. Maintain good oral hygiene on therapy.
Other	Ca, electrolytes, Hgb/Hct regularly but no defined time intervals. U/A every 3–6 months.	N/A	N/A	Calcium (1,600 mg/d) and vitamin D (400 lU/d) in patients in areas of decreased sun.
Choice of bisphosphanate	Pamidronate or zoledronic acid.Choice up to patient/physician.	Pamidronate or zoledronic acid.	Favor pamidronate over zoledronic acid due to risks of ONJ.	Pamidronate and zoledronic acid equally effective. Cloforobate (available in Europe) can be considered as well.

Abbreviations: MM, multiple myeloma; MGUS, monoclonal gammopathy of undetermined significance; SMM, smouldering multiple myeloma; ONJ, osteonecrosis of the jaw; N/A, not applicable; CrCl, creatinine clearance; U/A, urinalysis; CKD, chronic kidney disease; Ca, calcium; Hgb, hemoglobin; Hct, hematocrit; ASCO, American Society of Clinical Oncology; NCCN, National Comprehensive Cancer Network; EMN, European Myeloma Network.