There is increasing evidence that early treatment of smoldering myeloma with biphosphonates may e beneficial; however, the level of proof has nto yet reached the quality sufficient to change the guidelines or to modify existing coverage policies.
The recently published American Society of Clinical Oncology clinical practice guidelines for the use of bisphosphonates (BPs) in multiple myeloma do not recommend use of these drugs in patients with monoclonal gammopathies not requiring specific treatments, such as smoldering/indolent myeloma or monoclonal gammopathies of undetermined significance. The guidelines were updated in 2007 and continue to recommend that bisphosphonates not be given to myeloma patients with solitary plasmacytoma, smoldering or indolent disease, and monoclonal gammopathy of undetermined significance. The 2006 Mayo Clinic Consensus reached the same conclusion.
The most recent guideline is a European one from 2012. The panel recommends the use of biphoopshanates(BP)s in Multiple Myeloma patients suffering from lytic bone disease or severe osteoporosis. Intravenous administration may be preferable; however, oral administration can be considered for patients unable to make hospital visits. The panel agrees that BPs should be given for 2 years, but this may be extended if there is evidence of active myeloma bone disease. A recent article in 2013 New England of Medicine ( Mateos et al) suggested that high risk smoldering myeloma should be aggressively treated. This is remains controversial.
Smith A, Wisloff F, Samson D, UK Myeloma Forum, Nordic Myeloma Study Group, British Committee for Standards in Haematology. Guidelines on the diagnosis and management of multiple myeloma 2005. Br J Haematol 2006 Feb;132(4):410-51. [292 references]
NCCN.ORG, Myeloma, 2012
Lacy MQ, Dispenzieri A, Gertz MA, et al. Mayo Clinic consensus statement for the use of bisphosphonates in multiple myeloma. Mayo Clin Proc. 2006;81:1047-1053.
Terpos E, Sezer O, Croucher PI, et al. The use of bisphosphonates in multiple myeloma: recommendations of an expert panel on behalf of the European Myeloma Network. Ann Oncol 2009; 20:1303.
María-Victoria Mateos, M.D., Ph.D., Miguel-Teodoro Hernández, M.D., Pilar Giraldo, M.D., Javier de la Rubia, M.D., Felipe de Arriba, M.D., Ph.D., Lucía López Corral, M.D., Ph.D., Laura Rosiñol, M.D., Ph.D., Bruno Paiva, Ph.D., Luis Palomera, M.D., Ph.D., Joan Bargay, M.D., Albert Oriol, M.D., Felipe Prosper, M.D., Ph.D., Javier López, M.D., Ph.D., Eduardo Olavarría, M.D., Ph.D., Nuria Quintana, M.D., José-Luis García, M.D., Joan Bladé, M.D., Ph.D., Juan-José Lahuerta, M.D., Ph.D., and Jesús-F. San Miguel, M.D., Ph.D.
N Engl J Med 2013; 369:438-447August 1, 2013