1. Sarah Kunin, MD Princeton Baptist Medical Center Baptist Health Systems Alabama Multiple Myeloma: Treatment with Bisphosphonates

2. Introduction Topic:  Multiple Myeloma patients should receive treatment with bisphosphonates to help treat lytic lesions and prevent further bone disease Purpose:  Review physician reasons patients are excluded from starting bisphosphonate therapy in order to identify practice patterns and opportunities for quality improvement.  Ensure documentation is done in medical records to allow for optimal patient management and audit-readiness.

3. Literature Review American Society of Clinical Oncology 2007 Clinical Practice Guideline recommends use of bisphosphonates to prevent and treat bone disease in MM.  Indicated for patient with lytic destructive lesions of bone or spine compression fractures from osteopenia.  Treat for 2 year period. Continuation of treatment beyond 2 years is up to discretion of physician.  Severe renal impairment is a contraindication in IV zoledronic acid.

4. Methods Data abstracted from Clinic Charts for Dr. Vance and Dr. Lasker, NextGen EHR for Dr. Garcia and Dr. Hamilton, and EPIC hospital records. Captured data:  Date of initiation of bisphosphonates.  Contraindications for initiation of bisphosphonates  Diagnosis of Multiple Myeloma Stratification of reasons patients were or were not started on Bisphosphonates.

5. Criteria for Study Inclusion criteria  Patients aged 18 years and older  Diagnosed with MM not in remission  Those prescribed or received IV bisphosphonate therapy within 12 months of being diagnosed with MM Exclusion criteria:  Medical reasons for not prescribing bisphosphonates:  No bone disease, dental disease, renal insufficiency  Patient reasons for not prescribing  Refusing treatment, dies before able to initiate treatment  Systemic reason for not initiating bisphosphonate therapy

6. Patient Treatment People coded as documented with MM 52 Outside Study Criteria: Dx before trial period, followed at OSH, never progressed to MM 1 + 6 + 4 Evaluated for Bisphosphonate Therapy 41 Initiated IV Bisphosphonate 24 Did not initiate IV Bisphosphonates 17 Died before treatment 4 GFR <50 9 no lytic bone dz 2 Patient refused treatment 2

7. Summary of Findings All patients who met criteria for initiating IV bisphosphonate therapy were started on treatment. The patients who did not receive bisphosphonate therapy were excluded for medical or patient reasons. Percentage of patient evaluated for bisphosphonates that met criteria and received it was 59%. Percentage of patient evaluated for bisphosphonates who did not meet criteria and did not receive it: 41%.

8. Conclusions The physicians are appropriately providing bisphosphonate therapy for multiple myeloma patients who meet criteria. We could improve our documentation of reasons we do not give bisphosphonates when there is a medical reason to allow for clarity in the medical records.

9. Recommendations Discuss with Electronic Medical Records (Epic and NextGen) regarding an automated pop-up associated with diagnosis of Multiple Myeloma that includes criteria to start bisphosphonates and prompts the provider to document whether patient meets criteria to be started on bisphosphonates.

10. References Kyle, RA, Yee GC, et al. “American Society of Clinical Oncology 2007 Clinical Practice Guideline Update on the Roale of Bisphosphonates in Multiple Myeloma.” Journal of Clinical Oncology. 2007 Jun;25(17): 2464-72. Lacy MQ, Zispenzieri A, et al. “Mayo clinic consensus statement for the use of bisphosphonates in multiple myeloma.” Mayo Clin Proc. 2006 Aug;81(8): 1047- 53.