Biomarkers of bone loss currently have no role in the monitoring or optimisation of bisphosphonate therapy in myeloma bone disease, according to new guidelines from Myeloma Australia.
Although there is some evidence markers such as serum C-terminal telopeptide of type 1 collagen (CTX) can predict the risk of skeletal-related events, the markers are not recommended for routine use.
Co-author of the guidelines, Professor Andrew Zannettino from the University of Adelaide, told the limbic it was a contentious issue but the Medical and Scientific Advisory Group were mindful of international recommendations.
“We didn’t want to be too prescriptive with respect to biomarkers and certainly a number of them provide exquisite information on bone loss,” he said.
The guidelines also said there was insufficient evidence for bone resorption markers in predicating osteonecrosis of the jaw in patients requiring invasive dental procedures.
However renal function and serum calcium, phosphate and magnesium should be monitored regularly during therapy.
The guidelines recommend bisphosphonates in all symptomatic patients with multiple myeloma but not in smouldering myeloma or monoclonal gammopathy of undetermined significance (MGUS).
“While there is not great evidence to suggested improvement in survival with bisphosphonate therapy, there is great evidence they can demonstrably reduce skeletal events,” Professor Zannettino said.
Intravenous agents, either pamidronate or zoledronic acid, were the most effective agents but oral clodronate was an option for some patients as long as they meticulously followed dosing recommendations.
The guidelines said there was little evidence to indicate how long to continue therapy.
They recommended two years of treatment for patients with complete remission or very good partial remission; decreasing frequency of therapy to three-monthly internals after two years in patients with stable disease; and continuing monthly therapy for patients with active or progressive disease.
However any evidence of renal insufficiency, osteonecrosis of the jaw or atypical femoral fractures would be grounds to withdraw bisphosphonate treatment.
The guidelines also include recommendations for the prevention and management of osteonecrosis of the jaw.