Are Bisphosphonates Still the Standard of Care Recommendation?

This week's “Ask Dr. Durie” comes from a patient anxious to know if the management of bone disease in myeloma has changed. Are there new treatments or is the use of bisphosphonates—using Aredia® or Zometa®—still the standard of care recommendation?  

And fortunately, the answer is yes, we still do make those same recommendations with the use of Aredia or Zometa being the primary recommendations. 

Now, bisphosphonates limit bone destruction. They attack the osteoclasts that can destroy the bone. And so, they are very, very useful in the prevention of ongoing bone issues. So, this is the primary recommendation. At the start of treatment, it is important to have a full dental evaluation. This continues to be the case. The reason is that if you have dental issues, this can be a focal point for the development of something called osteonecrosis of the jaw—a destructive process triggered at the site of areas of bone damage at the bottom of your teeth. 

So, it is very, very important to have a dental evaluation, to have any issues taken care of before you start bisphosphonate therapy, and to keep good dental care during treatment. Once treatment is started, it should be continued monthly with Aredia or Zometa for two years—this is the standard recommendation.  

Now, many patients who are diagnosed with myeloma these days do not have significant, active bone pain or born destructive problems. And so, it's up to the discretion of the treating doctor to decide to reduce the frequency of the monthly infusions within those two years.  

After two years, the general recommendation is to stop therapy. However, if a patient has significant ongoing active bone problems, then at the discretion of the treating doctor, it may be that perhaps less frequent use of Aredia or Zometa can be considered. 

Now, an alternative to the bisphosphonates is a newer agent called Denosumab—XGEVA® is the commercial name. And this is a monoclonal antibody that can be shot once a month and it's an alternative to bisphosphonate therapy. It's primarily recommended for patients who have kidney problems, but it can be considered across the board.  

The BOTTOM LINE for bone treatment: Yes, bisphosphonates are still the main recommendation with Xgeva as a backup therapy, particularly for patients who may have kidney issues.