From the Guidelines
Bisphosphonates like pamidronate and clodronate are less likely to cause pain compared to zoledronic acid, as they have a lower risk of osteonecrosis of the jaw (ONJ) and similar benefits in reducing bone-related complications and improving quality of life. According to a study published in the Journal of the National Comprehensive Cancer Network 1, pamidronate and clodronate have been shown to reduce pain and bone-related complications in patients with multiple myeloma, with a lower risk of ONJ compared to zoledronic acid. The study found that zoledronic acid was associated with a 9.5-fold greater risk of ONJ compared to pamidronate.
When considering bisphosphonate therapy, it's essential to weigh the benefits and risks of each medication. The NCCN Guidelines for multiple myeloma recommend bisphosphonates or denosumab for all patients receiving therapy for symptomatic multiple myeloma, regardless of documented bone disease 1. However, the choice of bisphosphonate should be individualized based on patient factors, such as renal function and risk of ONJ.
Some key points to consider when prescribing bisphosphonates include:
- Monitoring renal function and adjusting the dose accordingly
- Conducting a baseline dental examination and monitoring for ONJ
- Considering the frequency of dosing (monthly vs every 3 months) based on individual patient criteria and response to therapy
- Being aware of the potential for acute-phase reactions with IV bisphosphonates and taking steps to minimize them, such as administering acetaminophen before and after infusion.
Overall, the choice of bisphosphonate should be based on the individual patient's needs and risk factors, with the goal of minimizing pain and maximizing quality of life. As noted in a study published in the Annals of Oncology 1, bisphosphonates can have a direct apoptotic effect on osteoclasts and inhibit their differentiation and maturation, making them a valuable treatment option for patients with bone-related complications.
From the Research
Bisphosphonates and Pain
- Bisphosphonates are effective inhibitors of bone resorption and reduce the risk of skeletal complications in patients with bone metastases 2.
- The standard routes of administration for bisphosphonates are either oral or intravenous (i.v.) infusion, with i.v. infusion being associated with dose- and infusion-rate-dependent effects on renal function 2.
- Newer, more potent bisphosphonates, such as zoledronic acid, can be administered via relatively short i.v. infusions without adversely affecting renal function 2.
Comparison of Bisphosphonates
- Zoledronic acid has demonstrated the broadest clinical activity in patients with bone metastases 2.
- Ibandronate and pamidronate require longer infusions compared to zoledronic acid 2.
- Denosumab was associated with significantly greater risk reduction than alendronate or ibandronate for vertebral and any fractures, but no difference in fracture risk reduction was found between zoledronate and denosumab 3.
Factors Influencing Bisphosphonate Selection
- The selection of osteoporosis treatment should be individualized and based on a variety of factors, including underlying fracture risk, medical comorbidities, medication burden, as well as fracture risk reduction profiles, modes of administration, and side effects of treatment options 4.
- Polypharmacy is associated with worse adherence to pharmacologic therapy, and the selection of osteoporosis treatment should take this into account 4.