Pamidronate

Indications
 Intravenous
Paget's disease of bone
Adult: 30 mg daily (over 4 hr) for 3 consecutive days (total dose: 90 mg), may repeat course when clinically indicated. Alternatively, 30 mg wkly for 6 wk (total dose: 180 mg) or 30 mg in the 1st wk, then 60 mg every other wk for 6 wk (total dose: 210 mg); may repeat course 6 mthly until remission of the disease is achieved, or relapse occurs. Max infusion rate: 60 mg/hr. Max total dose: 360 mg/course.
Elderly: Initiate with lower doses.
Renal impairment: Max infusion rate: 20 mg/hr.
CrCl (ml/min)Dosage Recommendation
<30Avoid.

Intravenous
Hypercalcaemia of malignancy
Adult: 15-90 mg (based on initial plasma calcium caoncentration) by slow infusion as a single dose over 2-24 hr or in divided doses over 2-4 days. Generally, plasma-calcium levels should start declining 24-48 hr after a dose with normalisation within 3-7 days. May repeat treatment if normocalcaemia is not achieved within this time or if hypercalcaemia recurs.
Elderly: Initiate with lower doses.
Renal impairment: Max infusion rate: 20 mg/hr.
CrCl (ml/min)Dosage Recommendation
<30Avoid.

Intravenous
Bone metastases
Adult: 90 mg every 3-4 wk. To be given as a 4-hr infusion.
Elderly: Initiate with lower doses.
Renal impairment: If renal function deteriorates: stop treatment until renal function is within 10% of baseline level. If reinstated, infuse over at least 4 hr.
CrCl (ml/min)Dosage Recommendation
<30Avoid, unless case is life threatening tumour induced hypercalcaemia.
30-60Max rate: 20 mg/hr


Reconstitution: Add 5 ml of sterile water for inj to a 15 mg of vial of lyophilised drug or 10 ml to vials containing 30 or 90 mg of lyophilised drug. Resulting solutions will contain 3 or 9 mg/ml of pamidronate disodium. Allow contents to completely dissolve before withdrawing a dose. Further dilution: 250-1000 ml of 0.45% or 0.9% sodium chloride or 5% glucose.
Incompatibility: Incompatible with calcium containing solutions such as lactated Ringer's.
Contraindications
 History of allergy to biphosphonates. Pregnancy.
Warnings / Precautions
 May increase the risk of heart failure in patients with cardiac disease. Lactation. Infuse slowly to reduce risk of adverse effects (e.g. infusion site reactions, renal impairment). Do not give as a bolus inj. Risk of neurotoxicity: Each dose should not >90mg (max concentration: 60 mg/250ml). CBC should be performed (patients with preexisting anemia, leukopenia or thrombocytopenia should be closely monitored within the 1st 2 wk of therapy). Bone, myalgia and/or arthralgia (possibly incapacitating) may develop days, mth, or yr after starting bisphosphonate; pain is distinctly different to the acute bone pain, myalgia or arthralgia which may follow administration and normally improves within several days; symptoms normally stop once therapy is discontinued; do not administer to patients with a history of these reactions associated with bisphosphonate therapy. Monitor creatinine before each dose, especially in those predisposed to renal impairment (withhold dose in patients with bone metastases whose renal function declines).
Adverse Reactions
 Ocurrence and severity of reactions depend on dose and duration of infusion. Anorexia, dyspepsia, nausea, abdominal pain, vomiting; metastases; fatigue; arthralgia, myalgia; anxiety, headache, insomnia, fever; flu-like symptoms; transient bone pain, hypocalcaemia; leucopenia; local reactions at infusion site; somnolence, dizziness, hypotension, rash; hypophosphataemia, hypokalaemia, hypomagnesaemia; osteonecrosis of the jaw (especially in cancer patients); vein irritation and thrombophlebitis; candidiasis; UTI; dyspnoea, cough, upper respiratory tract infections, sinusitis, pleural effusion; atrial fibrillation, hypertension, syncope, tachycardia; psychosis; constipation, GI bleed; uremia; rales, rhinitis.
Potentially Fatal: Acute renal and heart failure.
Overdose Reactions
 Hypocalcemia, hypotension, ECG changes, seizures, bleeding, paresthesia, carpopedal spasm, and fever. Treatment: IV calcium gluconate and supportive care; fever and hypotension treated with corticosteroids.
Drug Interactions
 Additive hypocalcaemic effect with aminoglycosides; decreased absorption with antacids (containing aluminium, calcium or magnesium), administer at a different time of day; decreased absorption with calcium salts; increases risk of GI adverse/toxic effects (especially GI ulcers) with NSAIDs; may increase hypocalcaemic effect of phosphate supplements.
See Below for More pamidronate Drug Interactions
Lab Interactions
 May interfere with diagnostic imaging agents in bone scans such as technetium-99m-diphosphonate.
Mechanism of Actions
 Pamidronate is an aminobisphosphonate that inhibits bone resorption by acting on osteoclasts and osteoclast precursors. It also inhibits tumour induced osteolysis and delays or prevents skeletal related events (e.g. fractures, spinal cord depression) and decreases bone pain in patients with lytic metastases.
Onset: 24-48 hr.
Duration: Peak effect: max 5-7 days.
Absorption: Poor absorption.
Excretion: Elimination half-life: 21-35 hr. Excretion: Biphasic; urine (approx 50% as unchanged drug) within 120 hr.
Storage Conditions
 Intravenous: Powder for reconstitution: Store <30°C. Solution for inj: Store <25°C. After reconstitution: Stable for up to 24 hr when refrigerated at 2-8°C.
ATC Classification
 M05BA03 - pamidronic acid ; Belongs to the class of bisphosphonates. Used in the treatment of bone diseases.
Storage
 Intravenous: Powder for reconstitution: Store <30°C. Solution for inj: Store <25°C. After reconstitution: Stable for up to 24 hr when refrigerated at 2-8°C.
Available As
  • Pamidronate 15 mg
  • Pamidronate 25 mg
  • Pamidronate 30 mg
  • Pamidronate 60 mg
  • Pamidronate 90 mg

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