Myeloma bone disease: Clinical features and complications
Dr Andrew Chantry - University of Sheffield, Sheffield, UK
My research interest is myeloma bone disease and looking for better treatments for this terrible consequence of myeloma. About 80% of patients present with examples of myeloma bone disease and through the course of their disease about 90% of them have serious problems with bone. The mainstay of treatment has been zoledronic acid, which is a very long-acting bisphosphonate that is given intravenously monthly, but does have some quite substantial disadvantages. You can’t use it in substantially renally impaired patients and it does cause some additional problems such as atypical femoral fractures and osteonecrosis of the jaw. Furthermore, zoledronic acid is extremely long-acting and effectively uncouples bone remodelling. So an alternative to zoledronic acid would be desirable.
Denosumab is another antiresorptive agent that targets osteoclasts in a different way. It’s a monoclonal antibody to the RANK ligand molecule that drives osteoclast recruitment. Denosumab is subcutaneously administered and can be used in patients who are renally impaired, so it would be quite an attractive option to use denosumab and also in combination with an anabolic agent if we get that option down the line. Another advantage with its subcutaneous administration is that it could be given in a domiciliary setting to take strain off hospital day wards.
Myeloma bone disease is an underestimated feature of myeloma and in terms of pain, loss of function, loss of employment, the psychological burden of disease is really something that we should try to do better for. We are looking at programs to improve the treatment, not just in terms of better drugs to treat it but also increased access to effective pain relief services, specialist palliative care doctors, better liaison with orthopaedic colleagues when surgical intervention is necessary, physiotherapy and holistic treatments that really bring all elements together to improve outcomes for patients.