Should individuals diagnosed with MGUS or SMM be receiving bisphosphonates?

[Music] should individuals diagnosed with em gas or smoldering myeloma be receiving this phosphonates there many studies on MCAS are smoldering multiple myeloma patients and the rule of bisphosphonates so far all the studies showed that this first relates should not be given in patients with M gas of smaller in light of in myeloma you cannot really prevent the progression of multiple myeloma when you have smaller in multiple myeloma and you're treated with bisphosphonates usually when patients come to my office and ask me I have bone loss should I get bisphosphonates my endocrinologist is recommending missus I recommend those patients that they should receive bisphosphonates according to the guidelines of endocrinology for bone loss for instance that they should receive this phosphonates only a year I would only start treatment with bisphosphonates in a monthly fashion like we do it for my myeloma and patients have over at my live in myeloma so that means only patients active multiple myeloma should receive bisphosphonate treatment for it most three years patients with M Gus as I mentioned earlier have much higher risk for fracture some around anywhere from one and a half for hip fracture up to about six volt higher perfect Ebro fracture so in general I tend to have a very low threshold for providing those patients with the bits phosphonate I would like to get a bone density scan done first which we typically do sort of to evaluate for osteoporosis but then recognizing that whatever that score is by bone density they likely have additional bone loss that's not been recognized and the reason for that is a little bit complicated but basically a bone density is a two dimensional imaging of your the amount of bone that's there obviously we know bone is not a two-dimensional structure bone is a three-dimensional structure and the bone density scan basically just can't differentiate that what we call the trabecular bone which is the inside part of the bone from the outside part of the bone which is called the cortical bone and it can't sort of provide the specific understanding of the changes in bone microstructure that are there so it's just not a very sensitive technique so if patients with MS have osteoporosis by bone density scanning well then the should definitely achieve like a standard osteoporosis patient which is typically to treat them as a bisphosphonate or other anti resort to therapy if they have normal bone density well then they're probably don't need to be treated the gray zone becomes if they're in the osteopenic range by bone density testing because those patients with osteopenia are at a higher risk for fracture than with normal not as high as with osteoporosis but I personally consider medications like this Boston is doing very safe I have a low threshold for starting patients with MDS and osteopenia on Abyss phosphonate typically recommend doses which are consistent with osteoporosis so a medication like a lender name which is generic Fosamax 70 milligrams once a week for about five years alternatively patients can't tolerate that then we'd consider intravenous zoledronic acid or reclassed which is a once a year IV medication typically for about three years I also counsel my patients that there are many other aspects of bone health besides besides pharmacologic agents so the first thing that I counsel my patients on with M gas is the importance of limiting the risk for having a fall their single greatest risk of having a broken bone is having a fall the second thing is limit to lifting and if they're gonna lift to do so with their straight back trying to bend their knees so that they don't put excess pressure on their spine the third thing is to say as active as possible so I like patients to walk or other weight-bearing activities for at least an hour in total daily it can be five or ten minutes at a time but they can't spend their day being a couch potato and the last thing is to ensure that they get enough calcium and vitamin D intake typically about a thousand international units of vitamin D and for most patients somewhere between about a thousand and 1200 milligrams of calcium that calcium can come from other food sources or it can come from calcium supplements but over the course of the day it needs to add up basically to about the numbers I just mentioned patient is smoldering multiple myeloma at a much higher risk for progression to multi myeloma but there also we think based upon some preliminary data we have at a higher risk for having a fracture like patients with them Gus I have a very low threshold for treating with a medication to limit the risk or bone loss typically of a patient a smoldering multiple myeloma obtained a bone density scan if there's any evidence for any fracture that patient would warrant of his phosphate therapy that could be either in the form of zoledronic acid or so meta or reclass provided once a year for at least three years or alternative legal under name 70 milligrams once a week provided for these five years they should also be counseled on the importance of limiting the risk for Falls limiting the lifting using a straight back when doing so maintaining an active lifestyle to include activities like skeletal loading such as walking or other weight for activities for at least an hour in total daily and maintaining adequate calcium and vitamin D intake vitamin D intake should typically be about a thousand international units a day and calcium typically between around a thousand maybe 1,200 milligrams a day [Music]