pamidronate

Contraindicated in:

Hypersensitivity to pamidronate, other biphosphonates, or mannitol
OB: Lactation: Pregnancy or lactation.

Use Cautiously in:

Underlying cardiovascular disease, especially HF (initiate saline hydration cautiously)
Invasive dental procedures, cancer, receiving chemotherapy or corticosteroids, poor oral hygiene, periodontal disease, dental disease, anemia, coagulopathy, infection, or poorly-fitting dentures (may ↑ risk of jaw osteonecrosis)
History of thyroid surgery (may be at ↑ risk for hypocalcemia)
Renal impairment (dose ↓ recommended)
Pedi: Safety not established.

Adv. Reactions/Side Effects ⬆ ⬇

EENT: conjunctivitis, blurred vision, eye pain/inflammation, rhinitis.

Neuro: fatigue.

Resp: rales.

CV: arrhythmias, hypertension, syncope, tachycardia.

GI: nausea, abdominal pain, anorexia, constipation, vomiting.

F and E: hypocalcemia, hypokalemia, hypomagnesemia, hypophosphatemia, fluid overload.

GU: nephrotoxicity.

Hemat: leukopenia, anemia.

Local: phlebitis at injection site.

Metab: hypothyroidism.

MS: muscle stiffness, musculoskeletal pain, femur fractures, osteonecrosis (primarily of jaw).

Misc: fever, generalized pain.

Interactions ⬆ ⬇

Drug-Drug:

Hypokalemia and hypomagnesemia may ↑ risk of digoxin toxicity.
Calcium and vitamin D will antagonize the beneficial effects of pamidronate.
Concurrent use of thalidomide may ↑ risk of renal dysfunction.

Route/Dosage ⬆ ⬇

Single doses should not exceed 90 mg

Hypercalcemia of Malignancy

IV (Adults): Moderate hypercalcemia — 30–90 mg; may be repeated after 7 days.

Osteolytic Lesions from Multiple Myeloma

IV (Adults): 90 mg monthly.

Osteolytic Lesions from Metastatic Breast Cancer

IV (Adults): 90 mg q 3–4 wk.

Paget’s Disease

IV (Adults): 90–180 mg/treatment; may be given as 30 mg daily for 3 days up to 30 mg/wk for 6 wk. Single doses of 60–90 mg may also be effective.

Implementation ⬆ ⬇

Initiate a vigorous saline hydration, maintaining a urine output of 2000 mL/24 hr, concurrently with pamidronate therapy. Patients should be adequately hydrated, but avoid overhydration. Use caution in patients with underlying cardiovascular disease, especially HF. Do not use diuretics prior to treatment of hypovolemia.
- Patients with severe hypercalcemia should be started at the 90-mg dose.
IV: Reconstitute by adding 10 mL of sterile water for injection to each vial. Concentration: 30 mg/10 mL or 90 mg/10 mL. Allow drug to dissolve before withdrawing. Solution is stable for 24 hr if refrigerated.
Hypercalcemia:
Rate: Administer 60-mg infusion over at least 4 hr and 90-mg infusion over 24 hr.
Multiple Myeloma:
Rate: Administer over 4 hr.
Paget’s Disease: Dilute reconstituted solution in 500 mL of 0.45% NaCl, 0.9% NaCl, or D5W.
Rate: Administer over 4 hr.
Y-Site Compatibility:
- acyclovir
- alemtuzumab
- alfentanil
- allopurinol
- amifostine
- amikacin
- aminophylline
- amphotericin B lipid complex
- amphotericin B liposome
- ampillicin
- ampicillin/sulbactam
- anidulafungin
- argatroban
- atracurium
- azithromycin
- aztreonam
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- carboplatin
- carmustine
- cefazolin
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- clindamycin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- daptomycin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxacurium
- doxorubicin
- doxorubicin liposomal
- doxycycline
- droperidol
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fenoldopam
- fentanyl
- fluconazole
- fludarabine
- fluorouracil
- foscarnet
- fosphenytoin
- furosemide
- ganciclovir
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- haloperidol
- heparin
- hydralazine
- hydrocortisone
- hydromorphone
- ifosfamide
- imipenem/cilastatin
- insulin
- isoproterenol
- ketorolac
- labetalol
- levofloxacin
- levorphanol
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- melphalan
- meperidine
- meropenem
- mesna
- metaraminol
- methotrexate
- methyldopate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- mitoxantrone
- morphine
- moxifloxacin
- mycophenolate
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- oxytocin
- paclitaxel
- palonosetron
- pancuronium
- pemetrexed
- pentamidine
- pentobarbital
- phenobarbital
- phentolamine
- phenylephrine
- piperacillin/tazobactam
- potassium acetate
- potassium chloride
- potassium phosphates
- procainamide
- prochlorperazine
- promethazine
- propranolol
- quinupristin/dalfopristin
- remifentanil
- rocuronium
- sodium acetate
- sodium bicarbonate
- sodium phosphates
- succinylcholine
- sufentanil
- tacrolimus
- theophylline
- thiopental
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- tolazoline
- topotecan
- trimethoprim/sulfamethoxazole
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zidovudine
Y-Site Incompatibility:
- amphotericin B deoxycholate
- caspofungin
- dantrolene
- diazepam
- leucovorin
- phenytoin
Additive Incompatibility: Calcium-containing solutions, such as Ringer’s solution.

US Brand Names ⬆ ⬇

Classifications ⬆ ⬇

Therapeutic Classification: bone resorption inhibitors

Pharmacologic Classification: biphosphonates, hypocalcemics

Availability ⬆ ⬇

(Generic available)

Powder for injection: 30 mg/vial; 90 mg/vial;

Time/Action Profile ⬆ ⬇

(effect on serum calcium)

ROUTE	ONSET	PEAK	DURATION
IV	24 hr	7 days	unknown

Assessment ⬆ ⬇

Monitor intake/output ratios and BP frequently during therapy. Assess for signs of fluid overload (edema, rales/crackles).
Monitor symptoms of hypercalcemia (nausea, vomiting, anorexia, weakness, constipation, thirst, and cardiac arrhythmias).
Observe for evidence of hypocalcemia (paresthesia, muscle twitching, laryngospasm, and Chvostek’s or Trousseau’s sign). Protect symptomatic patients by elevating and padding side rails; keep bed in low position.
Monitor IV site for phlebitis (pain, redness, swelling). Symptomatic treatment should be used if this occurs.
Assess for bone pain. Treatment with nonopioid or opioid analgesics may be necessary.

Lab Test Considerations:

Assess serum creatinine prior to each treatment. Withhold dose if renal function has deteriorated in patients treated for bone metastases.
- Monitor serum electrolytes (including calcium, phosphate, potassium, and magnesium), hemoglobin, and creatinine closely. Monitor CBC and platelet count during the first 2 wk of therapy. May cause hyperkalemia or hypokalemia, hypernatremia, and hematuria.
- Monitor renal function periodically during therapy.

Pot. Nursing Diagnoses ⬆ ⬇

Acute pain (Indications, Side Effects).
Risk for injury (Indications).

Patient/Family Teaching ⬆ ⬇

Advise patient to report signs of hypercalcemic relapse (bone pain, anorexia, nausea, vomiting, thirst, lethargy) or eye problems (pain, inflammation, blurred vision, conjunctivitis) to health care professional promptly.
Advise patient to notify nurse of pain at the infusion site.
Encourage patient to comply with dietary recommendations. Diet should contain adequate amounts of calcium and vitamin D.
Advise patient to notify health care professional if bone pain is severe or persistent.
Advise patient to maintain good oral hygiene and have regular dental examinations. Instruct patient to inform health care professional of pamidronate therapy prior to dental surgery.
Emphasize the need for keeping follow-up exams to monitor progress, even after medication is discontinued, to detect relapse.

Evaluation/Desired Outcomes ⬆ ⬇

Lowered serum calcium levels.
Decreased pain from lytic lesions.

Code ⬆

NDC Code^*

59923- Areva Pharmaceuticals Inc.
59923-601- Pamidronate Disodium 59923-601-10- 1 VIAL, SINGLE-DOSE in 1 CARTON (59923-601-10) > 10 mL in 1 VIAL, SINGLE-DOSE

59923- Areva Pharmaceuticals Inc.
59923-602- Pamidronate Disodium 59923-602-10- 1 VIAL, SINGLE-DOSE in 1 CARTON (59923-602-10) > 10 mL in 1 VIAL, SINGLE-DOSE

59923- Areva Pharmaceuticals Inc.
59923-603- Pamidronate Disodium 59923-603-10- 1 VIAL, SINGLE-DOSE in 1 CARTON (59923-603-10) > 10 mL in 1 VIAL, SINGLE-DOSE

61703- Hospira, Inc.
61703-324- Pamidronate Disodium 61703-324-18- 1 VIAL, SINGLE-DOSE in 1 CARTON (61703-324-18) > 10 mL in 1 VIAL, SINGLE-DOSE

61703- Hospira, Inc.
61703-325- Pamidronate Disodium 61703-325-18- 1 VIAL, SINGLE-DOSE in 1 CARTON (61703-325-18) > 10 mL in 1 VIAL, SINGLE-DOSE

61703- Hospira, Inc.
61703-326- Pamidronate Disodium 61703-326-18- 1 VIAL, SINGLE-DOSE in 1 CARTON (61703-326-18) > 10 mL in 1 VIAL, SINGLE-DOSE

67457- Mylan Institutional LLC
67457-430- Pamidronate Disodium 67457-430-10- 1 VIAL in 1 CARTON (67457-430-10) > 10 mL in 1 VIAL

67457- Mylan Institutional LLC
67457-446- Pamidronate Disodium 67457-446-10- 1 VIAL in 1 CARTON (67457-446-10) > 10 mL in 1 VIAL

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Pronunciation ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Contraind./Precautions ⬆ ⬇