Should I restart bisphosphonate therapy if I have a relapse and restart treatment?

Should I restart bisphosphonate therapy if I have a relapse and restart myeloma treatment after two years? When patients are treated with the medications like the bisphosphonates, they go in the vein, they circulate around and they lay on the surface of the bone. Even after you discontinue that medication, it's still going to be on the surface of your bone typically for at least a few years. So if someone has a relapse and they begin active myeloma therapy, part of that myeloma therapy often involves a medication like dexamethasone, which is very tough on the skeleton. So in that setting, we typically recommend restarting the bisphosphonate. Alternatively, if there's been any evidence for bone disease, like an osteolytic lesion has developed, then typically restarting the bisphosphonate therapy. Usually we like to ramp it up, maybe give it monthly for anywhere from three to six months. If the patient is doing well clinically, then it can start to be spaced out again a bit more every three months or every six months, perhaps even ultimately every once a year or something just to provide sort of general skeletal protection given the increased risk for bone loss and fractures that occur. Treatment really needs to be individualized and also based upon how the patients are doing clinically with their multiple myeloma. If it's under good control, then we can often back off significantly, recognizing that even when this medication isn't given, it continues to last and still be active for several years even after the last dose. I would even step back and say don't stop the bisphosphonates. I mean, maybe after 10 years, but as long as disease is there, as long as also maybe you get steroids with your treatment, I recommend to do bisphosphonates at least every three months. Usually our standard is, it's not scientifically proven, but our standard is that we do it once a month for one year, for 12 months, and then after that we go every three months. If patients are in a very deep remission for a very long time, then we even go to every six and every 12 months, but we still go on because we know that the bisphosphonates have an influence on the osteoclasts and those osteoclasts are interacting with myeloma cells, even if those myeloma cells are kind of dormant, where they're not very active. If we don't keep the activity of the osteoclasts down, that seems to stimulate the myeloma cells and kind of wake them up. So our recommendation is if there are no serious side effects, to go on with this treatment with this anti-bone resorptive treatment with bisphosphonates for actually forever.