What helps with bone pain in long bones after chemotherapy?

From the Guidelines

For pain in long bones after chemotherapy, External Beam Radiotherapy (EBRT) is the treatment of choice for localized moderate to severe bone pain due to bone metastases, with a single 8-Gy fraction recommended for painful uncomplicated bone metastases 1. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a multidisciplinary team in managing patients with bone metastases.

• Key considerations for managing bone pain in long bones after chemotherapy include:
  • The use of EBRT for localized bone pain
  • The administration of a single 8-Gy fraction for painful uncomplicated bone metastases
  • The importance of prophylactic antiemetics and dexamethasone to minimize nausea/vomiting and pain flare
  • The consideration of prophylactic surgery for impending fracture in long bones
• It is also crucial to evaluate structurally significant lesions in long bones by an orthopaedic surgeon to provide advice on suitability for surgery 1.
• Additionally, the use of bisphosphonates, such as zoledronate or denosumab, is recommended in patients with bone metastases, whether they are symptomatic or not, to prevent skeletal-related events 1.
• Non-drug approaches, such as gentle exercise, warm compresses, and adequate rest, can also help alleviate bone pain and improve quality of life.
• It is essential to inform the oncology team about persistent pain, as it may indicate a need to adjust the chemotherapy regimen or address other underlying issues.

From the FDA Drug Label

Zoledronic acid injection is indicated for the treatment of patients with multiple myeloma and patients with documented bone metastases from solid tumors, in conjunction with standard antineoplastic therapy. Zoledronic acid injection should be administered to patients with a creatinine clearance of ≥ 60 mL/min at a dose of 4 mg infused over no less than 15 minutes every 3 to 4 weeks.

• Zoledronic acid may help with bone pain in long bones after chemotherapy, as it is used to treat patients with multiple myeloma and patients with documented bone metastases from solid tumors.
• The recommended dose of zoledronic acid is 4 mg infused over no less than 15 minutes every 3 to 4 weeks for patients with creatinine clearance greater than 60 mL/min.
• Patients should also be administered an oral calcium supplement of 500 mg and a multiple vitamin containing 400 international units of vitamin D daily 2.

Pamidronate disodium is indicated for the treatment of moderate to severe hypercalcemia associated with malignancy, with or without bone metastases. In the breast cancer trials, there were four pamidronate disodium-related adverse experiences, all moderate in severity, that caused a patient to discontinue participation in the trial. One was due to interstitial pneumonitis, another to malaise and dyspnea. One pamidronate disodium patient discontinued the trial due to a symptomatic hypocalcemia Another pamidronate disodium patient discontinued therapy due to severe bone pain after each infusion, which the investigator felt was trial-drug-related.

• Pamidronate may help with bone pain in long bones after chemotherapy, as one patient discontinued therapy due to severe bone pain after each infusion.
• However, the primary indication for pamidronate is for the treatment of moderate to severe hypercalcemia associated with malignancy, with or without bone metastases 3.

From the Research

Management of Bone Pain

• Bone pain in long bones after chemotherapy can be managed with various treatments, including bisphosphonates, nonsteroidal anti-inflammatory drugs, and opioids 4, 5.
• Bisphosphonates, such as pamidronate and zoledronate, have been shown to reduce bone pain and prevent skeletal morbidity in patients with metastatic bone disease 4, 5.
• Nonsteroidal anti-inflammatory drugs, such as naproxen, can also be effective in reducing bone pain, particularly in patients receiving pegfilgrastim 6.
• Opioids, such as methadone, may be used to manage refractory cancer-induced bone pain when other opioids are ineffective or intolerable 7.

Treatment Options

• Pamidronate 90 mg i.v. delivered over 2 h every 3-4 weeks can be recommended in patients with metastatic breast cancer who have imaging evidence of lytic destruction of bone and who are concurrently receiving systemic therapy with hormonal therapy or chemotherapy 5.
• Naproxen 500 mg twice per day can be effective in reducing the incidence and severity of pegfilgrastim-induced bone pain 6.
• Methadone may be considered for patients with refractory cancer-induced bone pain, with a mean calculated daily dose of 25.7 mg (SD = 10.9) and a reduction in pain intensity of ≥ 30% and ≥ 50% in 70.2% and 53.2% of patients, respectively 7.

Prevention of Bone Pain

• Prophylactic fixation for long bone fractures is recommended in cases where 30 to 50% of the cortex has been destroyed, pain is present after radiotherapy, or life expectancy is more than 3 months 4.
• Regular pamidronate infusions can achieve a partial objective response according to conventional UICC criteria and can almost double the objective response rate to chemotherapy 5.
• Lifelong administration of oral clodronate to patients with breast cancer metastatic to bone reduces the frequency of morbid skeletal events by more than one-fourth 5.