IV Bisphosphonate (Paget's Disease / Bone Metastases / Hypercalcaemia) Pregnancy: Should not be given to pregnant women at any stage unless life-threatening hypercalcaemia cannot be controlled by any other means. Pamidronate may pose a risk to the foetus/newborn through its action on calcium homeostasis, and caused bone mineralisation defects in animals; there is insufficient clinical experience in pregnancy. Breast-feeding during therapy is not recommended.

Pamidronate Disodium

Brand names: Aredia, Pamidronate

Pamidronate disodium is an intravenous nitrogen-containing bisphosphonate used in conditions of increased bone turnover, including hypercalcaemia of malignancy, metastatic 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: Paget's disease of bone (the orthopaedic indication in this SPC): recommended total dose for a treatment course is 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 that treatment starts with an initial additional dose of 30 mg followed by 60 mg every other week (total 210 mg)

Route: Intravenous infusion only, after dilution. Pamidronate disodium must NEVER be given as a bolus injection. Each 30 mg or 60 mg dose should be diluted in 125 ml or 250 ml respectively of Sodium Chloride 0.9% w/v Intravenous Infusion BP. Insert the cannula carefully into a relatively large vein to minimise local reactions

Frequency: Paget's disease: 30 mg once weekly for 6 weeks, or 60 mg every other week (with or without an initial 30 mg dose). This regimen, or increased dose levels according to disease severity, can be repeated every 6 months until remission is achieved, and if relapse occurs

Max: Infusion rate must NEVER exceed 60 mg/hour (1 mg/min) and the concentration of pamidronate disodium in the infusion solution must not exceed 90 mg/250 ml. Paget's disease: repeat courses up to a maximum total dose of 360 mg (in divided doses of 60 mg). Tumour-induced hypercalcaemia: the maximum dose per treatment course is 90 mg, for both initial and repeat courses. A single 90 mg dose should normally be given as a 2 hour infusion in 250 ml of infusion solution

OTHER INDICATIONS IN THE SAME SPC. (1) Tumour-induced hypercalcaemia: rehydrate with 0.9% w/v sodium chloride before and during treatment. Total course dose depends on initial (uncorrected) 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. The total dose may be given as a single infusion or in multiple infusions over 2-4 consecutive days. Serum calcium usually falls at 24-48 hours and normalises within 3-7 days; if normocalcaemia is not achieved a further dose may be given, and treatment can be repeated whenever hypercalcaemia recurs. Pamidronate may become less effective as the number of treatments increases. (2) Osteolytic lesions and bone pain in multiple myeloma: 90 mg as a single infusion every 4 weeks. (3) Osteolytic lesions and bone pain in bone metastases associated with breast cancer: 90 mg as a single infusion every 4 weeks; may also be given at 3-weekly intervals to coincide with chemotherapy if desired. ADMINISTRATION CAUTIONS: in patients with established or suspected renal impairment (e.g. tumour-induced hypercalcaemia or multiple myeloma) the infusion rate should not exceed 22 mg/hour, and no more than 90 mg in 500 ml should be given over a 4 hour period. PAEDIATRIC USE: the SPC states there is no clinical experience in the paediatric and adolescent (under 18 years) population, the safety and efficacy of pamidronate in children has not been established, and until further experience is gained pamidronate disodium is only recommended for use in adult patients — therefore no paediatric dose has been recorded. HEPATIC IMPAIRMENT: no dose adjustment necessary in mild to moderate hepatic impairment; not studied in severe hepatic impairment, use with caution. Patients should be given the package leaflet and the patient reminder card.

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 the infusion rate should not exceed 90 mg/4 h (approximately 22 mg/h). Pamidronate disodium should NOT be given to patients with 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 group. Measure serum creatinine before each dose. In patients treated for bone metastases or multiple myeloma who show deterioration in renal function (rise of 0.5 mg/dL from a normal baseline creatinine, or 1.0 mg/dL from an abnormal baseline), 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 of more than 1 degree C lasting up to 48 hours), usually only after the first infusion and resolving spontaneously
Local soft tissue inflammation at the infusion site, especially at the highest dose
Anaemia, thrombocytopenia and lymphocytopenia (common)
Nausea, vomiting, abdominal pain, diarrhoea, constipation and gastritis (common)
Atrial fibrillation (frequency not known; more frequent than with zoledronate in one comparative trial)

Interactions

Do not co-administer pamidronate with other bisphosphonates (SPC §4.4)
Other calcium-lowering agents used together with pamidronate may cause significant hypocalcaemia (SPC §4.4)
Pamidronate disodium for injection must not be mixed with calcium-containing intravenous infusions (SPC §4.4 and §6.2)
Diuretic therapy: patients must be assessed before administration to ensure they are adequately hydrated to maintain urine output — especially important for patients on diuretics (SPC §4.4)

Clinical monograph

How it works

It binds to bone mineral and inhibits osteoclast-mediated bone resorption, reducing pathological bone breakdown and lowering serum calcium in hypercalcaemia.

Prescribing in practice

It must be given by slow intravenous infusion with the rate not exceeded as specified in the SPC, because rapid administration risks serious renal impairment.
Correct hypocalcaemia and ensure adequate hydration before infusion, and counsel on the risks of osteonecrosis of the jaw and atypical femoral fractures with bisphosphonate therapy.
An acute phase reaction with flu-like symptoms can occur after early infusions, and renal function should be assessed before dosing.

Monitoring

Monitor renal function and serum calcium and electrolytes before and during treatment, and review dental health where prolonged therapy is planned.

Counselling the patient

You may feel flu-like with fever or aching for a day or two after the first infusions.
Tell your team about any jaw pain or dental problems, or new thigh, hip or groin pain.
Maintain good dental hygiene and report reduced urine output or swelling.

Evidence & guidelines

Intravenous bisphosphonates such as pamidronate are established treatment for hypercalcaemia of malignancy and Paget's disease, with MHRA advice noting osteonecrosis of the jaw and atypical femoral fracture risks.

Reference: Glorieux et al. NEJM 1998 (OI); SIGN 142 (Paget's Disease); MHRA Drug Safety Update 2009 (ONJ); SPC Aredia; 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.

Calculators

Pathways