ASCO recommends the following for the use of bisphosphonates for multiple myeloma:

• Patients with multiple myeloma who experience bone loss or fractures of the spine from osteopenia (lower bone density that leads to weaker bones) should receive either pamidronate or zoledronic acid every three to four weeks. Each treatment of pamidronate should be at least two hours, and each treatment of zoledronic acid should be at least 15 minutes.
• Bisphosphonate treatment should be given for two years. At two years, bisphosphonate treatment may be stopped if it is working. Treatment should begin again if the myeloma comes back and new bone problems develop.
• To learn whether a bisphosphonate is causing kidney problems, the level of creatinine (a measure of kidney function) should be checked before each dose of pamidronate or zoledronic acid, and patients should be monitored every three to six months for albuminuria (high levels of the protein, albumin, in the urine that might indicate damage to the kidneys). The drugs should be stopped for patients who develop kidney problems while receiving a bisphosphonate, but they may be resumed once the problem is identified and resolved.
• The dose of pamidronate should be lowered in patients with pre-existing mild to moderate kidney disease. The maker of zoledronic acid previously recommended lowering the treatment dose for these patients.
• For patients with existing severe kidney problems and extensive bone disease, a longer infusion (4 to 6 hours) of pamidronate is recommended instead of a two-hour infusion. Zoledronic acid is not recommended for these patients.
• Osteonecrosis of the jaw is an uncommon but potentially serious side effect of pamidronate and zoledronic acid. Before treatment, patients should receive a thorough dental examination, and any tooth or mouth infections should be treated. While receiving bisphosphonate treatment, patients should avoid having any invasive dental work done, such as dental surgery, and take good care of their teeth, mouth, and gums.
• Bisphosphonates may be used to treat pain from bone disease. For patients who are already experiencing bone pain, bisphosphonates may be used along with other standard methods to relieve pain, such as radiation therapy, pain medication, or surgery for bone fractures.

Bisphosphonates are not recommended for patients with the following conditions:

• Solitary plasmacytoma (one bone tumor)
• Smoldering (indolent) myeloma
• Conditions of abnormal plasma cells that are not myeloma but may eventually develop into myeloma, such as monoclonal gammopathy of undetermined significance (MGUS)

The use of biochemical markers to monitor bisphosphonate treatment is not recommended.