Treatment of Multiple Myeloma with Osteolytic Bone Disease

Clinical Scenario

Patients diagnosed with multiple myeloma who have osteolytic bone disease at presentation face an elevated risk of skeletal complications — including pathological fractures, severe bone pain, and spinal cord compression. All such patients require bone-protective management as part of their overall treatment plan, in addition to myeloma-directed therapy.

Treatment Approach

Management centres on antiresorptive therapy, with agent selection guided by the patient's renal function, combined with mandatory supplementation and a range of additional bone-directed interventions for pain control, fracture prevention, and structural stabilisation.

Full criteria, agent selection, sequencing, and procedural indications are available in the complete protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1038/s41571-025-01041-x

All patients with MM with osteolytic disease at diagnosis should receive antiresorptive agents, such as zoledronic acid or denosumab [I, A], in addition to myeloma-directed therapy (Box 2).
In patients with severe renal impairment aminobisphosphonates are not recommended because they are cleared through the kidneys. Denosumab is a reasonable option but caution is needed owing to a high risk of hypocalcaemia [III, C].
Vitamin D and calcium supplementation is mandatory when administering either bisphosphonates or denosumab [I, A].
Low-dose radiotherapy (up to 30 Gy) can be used as palliative treatment for uncontrolled bone pain, impending pathological fracture or impending spinal cord compression [II, A].
Balloon kyphoplasty should be considered for symptomatic vertebral compression fractures with refractory pain [II, B].
Surgery is recommended for long-bone fractures, bony compression of the spinal cord or vertebral column instability [II, A].

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