Bisphosphonate Pregnancy: Should not be given to pregnant women at any stage unless life-threatening hypercalcaemia cannot be controlled by any other means — there is insufficient clinical experience in pregnancy and pamidronate may pose a risk to the fetus/newborn through its action on calcium homeostasis (bone mineralisation defects seen in animals). Breast-feeding during therapy is not recommended.

Pamidronate disodium

Brand names: Aredia

An intravenous nitrogen-containing bisphosphonate given by slow infusion for hypercalcaemia of malignancy, osteolytic bone disease and Paget's disease of bone.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Tumour-induced hypercalcaemia: total dose per treatment course determined by initial serum calcium — up to 3.0 mmol/L (up to 12.0 mg%): 15-30 mg; 3.0-3.5 mmol/L (12.0-14.0 mg%): 30-60 mg; 3.5-4.0 mmol/L (14.0-16.0 mg%): 60-90 mg; above 4.0 mmol/L (above 16.0 mg%): 90 mg

Route: Intravenous infusion ONLY — must never be given as a bolus injection; must be diluted before use and infused slowly

Frequency: Total course dose given as a single infusion or as multiple infusions over 2-4 consecutive days; the course may be repeated whenever hypercalcaemia recurs

Max: 90 mg per treatment course for both initial and repeat courses. Infusion rate must never exceed 60 mg/hour (1 mg/min) and the concentration in the infusion solution must not exceed 90 mg/250 mL

Rehydrate with 0.9% w/v sodium chloride solution before and during treatment for tumour-induced hypercalcaemia. Serum calcium usually falls significantly 24-48 hours after administration, with normalisation usually achieved within 3 to 7 days; if normocalcaemia is not achieved in this time a further dose may be given. Pamidronate may become less effective as the number of treatments increases. OTHER LICENSED INDICATIONS (UK SPC): Osteolytic lesions and bone pain in multiple myeloma — 90 mg as a single infusion every 4 weeks. Osteolytic lesions and bone pain in bone metastases associated with breast cancer — 90 mg as a single infusion every 4 weeks, which may instead be given at 3-weekly intervals to coincide with chemotherapy if desired. Paget's disease of bone — recommended total course dose 180 to 210 mg, given either as 6 unit doses of 30 mg once a week (total 180 mg) or as 3 doses of 60 mg every other week; if 60 mg unit doses are used it is recommended to start with an additional initial 30 mg dose followed by 60 mg every other week (total 210 mg). Each 30 mg or 60 mg dose should be diluted in 125 mL or 250 mL 0.9% w/v sodium chloride respectively, and the infusion rate should not exceed 60 mg/hour (1 mg/min). This regimen, or increased dose levels according to disease severity up to a maximum total dose of 360 mg in divided 60 mg doses, can be repeated every 6 months until remission and if relapse occurs. ADMINISTRATION: a single 90 mg dose should normally be given as a 2-hour infusion in 250 mL of infusion solution; in patients with established or suspected renal impairment (e.g. tumour-induced hypercalcaemia or multiple myeloma) no more than 90 mg in 500 mL should be given over a 4-hour period and the infusion rate should not exceed 22 mg/hour. Insert the cannula carefully into a relatively large vein to minimise local reactions. HEPATIC IMPAIRMENT: no dose adjustment necessary in mild to moderate hepatic impairment; not studied in severe hepatic impairment — administer with caution. PAEDIATRIC: until further experience is gained pamidronate is only recommended for use in adult patients; there is no clinical experience in the paediatric and adolescent (under 18 years) population and safety and efficacy in children have not been established.

Dose adjustments

Renal

No dose adjustment is necessary in mild (creatinine clearance 61 to 90 mL/min) to moderate (creatinine clearance 30 to 60 mL/min) renal impairment, but in such patients the infusion rate should not exceed 90 mg/4 h (approximately 22 mg/hour). Should not be administered in severe renal impairment (creatinine clearance below 30 mL/min) unless in life-threatening tumour-induced hypercalcaemia where benefit outweighs risk — no dose recommendation can be made for this population. Measure serum creatinine prior to each dose. In patients treated for bone metastases or multiple myeloma who show deterioration in renal function (increase of 0.5 mg/dL if baseline creatinine normal, or 1.0 mg/dL if abnormal), withhold treatment until renal function returns to within 10% of baseline. If renal function deteriorates during an infusion, the infusion must be stopped.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to pamidronate, to any of the excipients, or to other bisphosphonates

Side effects

Hypocalcaemia (very common; usually asymptomatic) and hypophosphataemia (very common)
Influenza-like symptoms with mild fever (temperature rise above 1 degree C lasting up to 48 hours), usually only after the first infusion
Local soft tissue inflammation at the infusion site, especially at the highest dose
Nausea, vomiting, abdominal pain, diarrhoea, constipation, gastritis (common)
Anaemia, thrombocytopenia, lymphocytopenia (common)
Paraesthesia, headache, somnolence (common); hypertension (common); atrial fibrillation (frequency not known)

Interactions

Other bisphosphonates — do not co-administer with pamidronate (§4.4)
Other calcium-lowering agents — significant hypocalcaemia may result if used in conjunction with pamidronate (§4.4)
Calcium-containing intravenous infusions — pamidronate for injection must not be mixed with these (§4.4, §6.2)
Diuretic therapy — patients must be assessed before administration to ensure adequate hydration to maintain urine output; this is especially important in patients receiving diuretics (§4.4)
(NOTE: eMC §4.5 was not captured in the bundle; the above are drawn from §4.4 of the fetched SPC)

Clinical monograph

How it works

It binds avidly to bone mineral and inhibits osteoclast-mediated bone resorption, thereby lowering serum calcium and reducing skeletal complications.

Prescribing in practice

It must be given as a slow intravenous infusion and never as a bolus, because rapid administration risks serious renal impairment, and the patient should be adequately hydrated beforehand.
Correct hypocalcaemia and ensure adequate vitamin D before treatment, and counsel on the small risk of osteonecrosis of the jaw, encouraging dental review beforehand.
An acute-phase reaction with transient flu-like symptoms is common after the first infusion.

Monitoring

Monitor serum calcium and other electrolytes, renal function before and after infusions, and assess oral health for signs of jaw osteonecrosis.

Counselling the patient

Flu-like symptoms with fever and aches may occur for a day or two after the first infusion and then settle.
Maintain good dental hygiene and report any jaw pain, swelling or non-healing dental problems.
Report numbness, tingling or muscle cramps, which may signal low calcium.

Evidence & guidelines

Intravenous bisphosphonates are established first-line treatment for hypercalcaemia of malignancy and for reducing skeletal events in metastatic bone disease, supported by oncology and endocrine guidance.

Reference: NICE; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

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