Managing Bone Disease With Multiple Myeloma

Posted: Feb 23, 2018

Bone disease is a common but challenging complication of multiple myeloma. More than 80% of myeloma patients suffer from bone lesions leading to pain, fractures, spinal cord compression and mobility issues. In normal bone developments, osteoclasts are cells that breaks down bone so it can be re-absorbed by the body. Osteoblasts generate new bone. These two processes usually work in harmony to constantly regenerate new bone while eliminating old bone.

In myeloma, this harmony is disrupted. The osteoclast process is increased while the osteoblast process is decreased, causing bone destruction in two ways.

Myeloma bone disease can impact overall survival. Myeloma patients who develop pathologic fractures have a 20% increased risk of death. As many patients know, managing bone pain or other bone issues also increases treatment costs.

Myeloma patients with bone disease need not only anti-myeloma treatment, but treatment to strengthen bone, provide pain control and some patients may need radiotherapy or surgical interventions.

The first step in bone disease management is to start therapy that will eliminate the myeloma. This can include the use of drug combinations such as a proteasome inhibitor, immunomodulatory drug, steroid, monoclonal antibody or stem cell transplant procedure.

According to an NIH article, other bone-specific treatment can include:

Bone Strengtheners

Bone strengtheners such as bisphosphonates or monoclonal antibodies can be given to strengthen bone. Typically, bisphosphonates like Zometa or Aredia are given monthly and then treatment is tapered off and given on a quarterly basis or stopped over time, depending on the status of the multiple myeloma. They are typically given through IV.

A new monoclonal antibody bone strengthener called denosumab is now FDA approved and is particularly helpful for patients with kidney issues. The bisphosphonates are filtered through the kidneys while denosumab is not. It is key to know that denosumab should be continued. If it is stopped, the osteoclasts can continue to destroy bone unless a single dose of a bisphosphonate is given following treatment, according to Matthew Drake, MD of the Mayo Clinic.

The bone strengtheners can reduce pain, fractures and hypercalcemia and have some anti-myeloma effects by themselves. Patients on long-term bone strengtheners should be monitored for side effects like kidney toxicity and osteonecrosis of the jaw (ONJ). Maintaining proper oral care is key for ONJ and a dental review or invasive dental procedures are recommended before starting on bone strengtheners.

Pain control

The majority of myeloma patients (70–80%) suffer from pain, and this could be the major complaint at the time of diagnosis. Experts recommend using a pain assessment scale from 0-10. A score of 5 or above would be moderate to severe pain and patients should be referred to a pain management team. For mild pain, Tylenol or similar paracetamol can be used. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) like aspirin, Motrin, Advil or Aleve should be avoided because they could affect the kidneys. Patients with moderate to severe pain may need opioids like tramadol, oxycodone, fentanyl patches, and morphine. However, side effects from these opioids (like sedation, neurological effects and constipation) should be watched in all patients, especially the elderly.

Radiotherapy

Historically, radiotherapy has been an important part of myeloma treatment. Radiotherapy can be used if a patient has a single bone plasmacytoma and could be curative in some cases. It can also be used as a pain control measure, reduce spinal cord compression, pathological fractures, soft tissue plasmacytomas, and control local neurological symptoms. The major risk of radiotherapy is permanent bone marrow damage, which can affect the ability to harvest stem cells for future transplants. The most common use of radiotherapy is for pain control, which historically has provided a 90% success rate.

Vertebroplasty/kyphoplasty

This is a minimal invasive procedure, carried out under local or general anesthesia. Vertebroplasty includes the injection of bone cement into a vertebrae to stabilize the bone or to provide pain relief. Kyphoplasty is the same type of procedure where inflatable balloon is placed into the vertebral body to expand it and then followed by injection of bone cement. Potential complication of this procedure is cement leakage which could cause nerve irritation or cord compression and embolization of cement.

Surgery

Surgery plays a role for myeloma patients who fracture long bones. Other uses may be for unresolved pain after non-surgical measures, spinal instability, spinal cord compression. For patients who require surgery, their myeloma specialist or hematologist should be consulted before any decisions are made.

The Importance of Imaging

It is critical that myeloma patients obtain the proper imaging tests when bone pain is present. X-rays are not helpful but MRIs and PET-CT scans can help identify tumors that may be affecting bone. Bone pain may indicate relapse, so never ignore a pain you think may go away on its own if you are a myeloma patient.

about the author
Jennifer Ahlstrom

Myeloma survivor, patient advocate, wife, mom of 6. Believer that patients can help accelerate a cure by weighing in and participating in clinical research. Founder of HealthTree Foundation (formerly Myeloma Crowd).