Should an 80-year-old male with suspected multiple myeloma and osteoporosis, as indicated by a Dual-Energy X-ray Absorptiometry (DEXA) scan, start taking Fosamax (alendronate)?

From the Guidelines

For an 80-year-old male with suspected multiple myeloma and osteoporosis on DEXA scan, starting Fosamax (alendronate) is not recommended until the multiple myeloma workup is completed. The primary concern in this patient is the suspected multiple myeloma, which can cause bone loss and fractures through different mechanisms than primary osteoporosis [ 1 ]. According to the NCCN Guidelines for MM, bisphosphonates (category 1) or denosumab are recommended for all patients receiving therapy for symptomatic MM regardless of documented bone disease [ 1 ].

Key Considerations

• Multiple myeloma itself can cause bone loss and fractures, and treatment should target the underlying malignancy first [ 1 ].
• If multiple myeloma is confirmed, the treatment approach would typically include anti-myeloma therapy along with bone-targeted agents like zoledronic acid (Zometa) or denosumab (Xgeva), rather than oral bisphosphonates like Fosamax [ 1 ].
• These intravenous or subcutaneous medications are preferred in myeloma because they more effectively reduce skeletal-related events in this population [ 1 ].
• Before starting any bisphosphonate therapy, the patient should have a dental evaluation to assess for risk of osteonecrosis of the jaw, and kidney function should be evaluated since both multiple myeloma and bisphosphonates can affect renal function [ 1 ].

Treatment Approach

• The NCCN Guidelines for MM recommend continuing bone-targeting treatment (bisphosphonates or denosumab) for up to 2 years; continuing beyond 2 years should be based on clinical judgement [ 1 ].
• The frequency of dosing (monthly vs every 3 months) would depend on the individual patient criteria and response to therapy [ 1 ].
• Denosumab is preferred by the NCCN MM Panel in patients with renal disease [ 1 ].

Next Steps

• Complete the multiple myeloma workup to determine the best course of treatment.
• If osteoporosis is determined to be unrelated to myeloma, then osteoporosis treatment can be reconsidered based on fracture risk assessment.

From the FDA Drug Label

Osteoporosis in Men Treatment of men with osteoporosis with alendronate sodium 10 mg/day for two years reduced urinary excretion of cross-linked N-telopeptides of type I collagen by approximately 60% and bone-specific alkaline phosphatase by approximately 40%.

The patient, an 80-year-old male with osteoporosis, should consider starting alendronate (Fosamax), as it has been shown to be effective in treating osteoporosis in men. However, the decision to start alendronate should be made after careful consideration of the patient's overall health and medical history, and under the guidance of a healthcare professional. 2

From the Research

Treatment Options for Multiple Myeloma with Osteoporosis

• The patient's DEXA scan shows osteoporosis, which is a common complication in multiple myeloma patients 3.
• Bisphosphonates, such as alendronate, pamidronate, and zoledronic acid, are effective in preventing and treating bone disease in multiple myeloma 4, 5, 6.
• The choice of bisphosphonate and duration of therapy are important considerations, given the risk of complications such as osteonecrosis of the jaw 4.

Fosamax (Alendronate) as a Treatment Option

• Alendronate is a bisphosphonate that has been shown to be effective in reducing the risk of vertebral fractures in multiple myeloma patients 3.
• A study comparing alendronate to pamidronate, zoledronic acid, and denosumab found that alendronate had a lower risk of osteonecrosis of the jaw 3.
• The Mayo Clinic consensus statement recommends the use of intravenous pamidronate and intravenous zoledronic acid as first-line treatments for multiple myeloma bone disease, but suggests that alendronate may be a suitable alternative 4.

Considerations for Starting Fosamax

• The patient's age and overall health should be taken into consideration when starting Fosamax, as well as the potential risks and benefits of treatment 4.
• Regular monitoring of the patient's bone density and renal function is recommended to minimize the risk of complications 6.
• The patient should be informed of the potential risks and benefits of Fosamax and alternative treatment options, and involved in the decision-making process 5.