I generally recommend bone-targeted treatment for patients who don’t have active bone disease, in keeping with the results of the Myeloma IX trial. I administer therapy monthly for 2 years and then after that every 3 months.

I do not recommend bone-targeted therapy for patients who do not have active bone disease. The NCCN guidelines were changed after the results of the MRC IX trial by Morgan and colleagues was published. However, they are only guidelines. I don’t believe the data are relevant in the setting of good myeloma therapy. I’m also concerned about toxicity.

In our practice we have been monitoring patients with DEXA scans early on. So we’re detecting osteoporosis in patients in the absence of lytic disease. I would approach treatment for these patients as I would for patients with active bone disease.

If patients have a normal DEXA scan, then I would treat for 2 years and then switch to a quarterly schedule. I would continue treatment until disease progression. The only exception would be if the therapy is not well tolerated.

I would recommend bone-targeted treatment for patients who don’t have active bone disease for a minimum of 2 years. The IMWG guidelines on bisphosphonates recommend that patients with active myeloma receive treatment for a minimum of 2 years even in the absence of overt bone disease.

After 2 years I reassess the patient and, based on how active their disease is, I might consider prolonging therapy. Some patients don’t present with bone disease but then 2 years later they have bone disease. I do not make a distinction based on risk status because I haven’t seen good data on that.

We propose bone-targeted therapy even if patients don’t have active bone disease. We know that even without any sign of active bone disease, there is bone loss in MM. If the clinical presentation is mostly anemia and not bone disease, we still recommend bone-targeted treatment. Because the duration of induction treatment with MPT or VMP is 1 year, we recommend the same duration of therapy for bone disease.

I follow the IMWG guidelines that recommend bisphosphonate therapy for 2 years. But my approach is more conservative for a patient who has achieved a stringent complete response, and I might not administer bisphosphonates then. Benefits of bisphosphonate therapy are observed in the relapsed/refractory setting or for patients who have a high tumor burden.

I administer bone-targeted therapy during induction for patients without active bone disease. I may not necessarily keep these patients constantly on the bisphosphonate. My rationale for administering a bisphosphonate is that I see it as an agent that affects the microenvironment.

The MRC Myeloma IX data suggest that whether or not patients had a skeletal-related event or bone lesion at the outset, those who received zoledronic acid had an improvement in disease-free survival. Patients who received this therapy had a decrease in the number of osteolytic lesions and a better progression-free survival.

I recommend that patients should receive a bisphosphonate even if they don’t have active bone disease. I would favor a 2- to 3-monthly schedule and continuing therapy indefinitely, unless there’s toxicity, in which case I would reduce the frequency.