Should bone-directed agents, such as denosumab or zoledronic acid, be given when patients are being treated with radium-223?

In ALSYMPCA, bisphosphonate use at study entry was associated with a delay in symptomatic skeletal events (Sartor, et al. Lancet Oncol 2014; 15(7) 738-46). Based on this, osteoclast-targeted agents (i.e. zoledronic acid and denosumab) should be offered to patients with mCRPC that will receive radium-223. There is certainly, no reason that osteoclast-targeted agents should be avoided in patients that will be treated with radium-223.