Optimal use of bisphosphonates in patients with multiple myeloma.

A 71-year-old woman presented with extreme low back pain. Her lumbar spine radiographs revealed a pathological fracture of L4. The hematology profile was normal (hemoglobin: 12.6 g/dL). The serum electrophoresis revealed an “M”-protein of 39 g/L and the immunofixation showed an immunoglobulin (Ig) G-l paraprotein. The bone marrow trephine biopsy demonstrated a clonal plasma-cell infiltration of 35%. The diagnosis of IgG-l multiple myeloma was made. The skeletal survey using conventional radiography showed an L4 fracture but no lytic lesions in the skeleton. The magnetic resonance imaging (MRI) of the lumbar spine and the pelvis revealed a diffuse pattern of marrow infiltration. The patient had normal creatinine (1.1 mg/dL; estimated glomerular filtration rate by Chronic Kidney Disease Epidemiology Collaboration formula was 51 mL/min/1.73 m) and normal serum calcium (9.9 mg/dL) levels. How should we manage bone disease in this myeloma patient?