Revised: 14 January 2008
SYNONYM(S): Pamidronate disodium, pamidronic acid, APD, aminohydroxypropylidene bisphosphonate
COMMON TRADE NAME(S): AREDIA® (first notice of compliance,1 26 February 1992; patent expires2 13 June 2006)
CLASSIFICATION: Bone metabolism regulator, noncytotoxic
MECHANISM OF ACTION:
Pamidronate is a second-generation bisphosphonate, which inhibits bone resorption.3 Bisphosphonates are analogues of endogenous pyrophosphate and characterized by a P-C-P bond, which is resistant to enzymatic hydrolysis.4 The mechanism of action of bisphosphonates has not been fully elucidated. Available data suggests that they bind strongly to hydroxyapatite crystals in the bone matrix, preferentially at the sites of increased bone turnover and inhibit the formation and dissolution of the crystals. Other actions of matrix-bound bisphosphonates may include direct inhibition of mature osteoclast function, promotion of osteoclast apoptosis and interference with osteoblast-mediated osteoclast activation.5 Pamidronate does not interfere with bone mineralization at therapeutic doses.3 On a molar basis, pamidronate is 10 times more potent than clodronate.4 In tumour-induced hypercalcemia, bone resorption is increased in the presence of neoplastic tissue. Pamidronate inhibits abnormal bone resorption and reduces the flow of calcium form the resorbing bone into the blood, thus, decreasing total and ionized serum calcium. In the treatment of osteolytic bone metastases in breast cancer and multiple myeloma, pamidronate helps reducing morbidity of bone metastases by inhibiting accelerated bone resorption induced by the tumour.6
PHARMACOKINETICS:
|
Interpatient variability |
no information found |
|
Oral Absorption |
<1% absorbed7 |
|
Distribution |
45-53% is adsorbed to bone in the areas of high turnover after an intravenous dose of 60 mg infused over 24 hours.6 Body retention of pamidronate correlates with the number of bone metastases in patients with cancer.5 |
|
cross blood brain barrier? |
no information found |
|
volume of distribution |
no information found |
|
plasma protein binding |
54%6 |
|
Metabolism |
does not appear to be metabolized |
|
active metabolite(s) |
none |
|
inactive metabolite(s) |
none |
|
Excretion |
renal excretion; there is a tendency for renal clearance to correlate with creatinine clearance. |
|
urine |
20-55% as unchanged drug within 72 hours |
|
terminal half life |
27 hours |
|
clearance |
180 mL/min |
|
Gender |
no information found |
|
Elderly |
no information found |
|
Children |
no information found6 |
|
Ethnicity |
no information found |
Adapted from reference 8 unless specified otherwise
USES:
|
Primary uses: |
Other uses: |
|
*Tumour-induced hypercalcemia9-11 |
Bone loss due to androgen suppression in prostate cancer12 |
|
*Osteolytic bone metastases13-17 |
|
|
|
|
*Health Canada approved indication
SPECIAL PRECAUTIONS:
Contraindicated in patients who have a history of hypersensitivity reaction to pamidronate or other bisphosphonates.6,8
Hydration: In the treatment of acute tumour-induced hypercalcemia, patients must be adequately hydrated with intravenous NS (0.9% NaCl) before and during pamidronate therapy to expand intracellular volume and to increase renal calcium clearance.9,11 The optimum infusion rate of NS should be determined by the severity of hypercalcemia, the degree of dehydration and the ability of the patient to tolerate fluid. Infusion rate of 200-300 mL/h has been commonly used. However, these infusion rates may require adjustment if signs and symptoms of fluid overload occur.11
Carcinogenicity: Studies on rats and mice did not find pamidronate to have carcinogenic potential.8
Mutagenicity: Pamidronate was not mutagenic in Ames test, mammalian in vitro mutation test or mammalian in vivo chromosome test.8
Fertility: No information found.6
Pregnancy: FDA Pregnancy Category C.6 Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.
Breastfeeding is not recommended due to the potential secretion into breast milk.8
SIDE EFFECTS:
The table includes adverse events that presented during drug treatment but may not necessarily have a causal relationship with the drug. Because clinical trials are conducted under very specific conditions, the adverse event rates observed may not reflect the rates observed in clinical practice. Adverse events are generally included if they were reported in more than 1% of patients in the product monograph or pivotal trials, and/or determined to be clinically important (reference expert reviewer). When placebo-controlled trials are available, adverse events are included if the incidence is >5% higher in the treatment group.
ORGAN SITE |
SIDE EFFECT |
|
Clinically important side effects are in bold, italics |
|
blood/bone marrow/
febrile neutropenia |
anemia* (35%) |
|
granulocytopenia* (17%) |
|
|
lymphocytopenia (1-10%) |
|
|
thrombocytopenia* (11%) |
|
constitutional symptoms |
asthenia* (16%) |
|
|
fatigue* (30%) |
|
|
fever (36%) |
|
dermatology/skin |
extravasation hazard: none |
|
injection site reaction (2%) |
|
gastrointestinal |
emetogenic potential: nonemetogenic |
|
anorexia* (21%) |
|
|
constipation* (28%) |
|
|
diarrhea* (24%) |
|
|
dyspepsia* (14%) |
|
|
nausea* (48%) |
|
|
vomiting* (31%) |
|
infection |
upper respiratory infection* (20%) |
|
|
urinary tract infection* (15%) |
|
metabolic/laboratory |
hypocalcemia (3%) |
|
|
hypomagnesemia (1-10%) |
|
|
hypophosphatemia (>10%) |
|
musculoskeletal |
osteonecrosis of the jaw (rare)18-20 |
|
neurology |
insomnia* (18%) |
|
ocular/visual |
conjunctivitis (rare)17 |
|
|
uveitis (rare)17 |
|
pain |
abdominal pain* (17%) |
|
|
headache* (24%) |
|
|
myalgia (23%) |
|
|
skeletal pain (59%) |
|
pulmonary |
cough* (21%) |
|
|
dyspnea* (23%) |
|
syndromes |
flu-like symptoms (>10%) |
Adapted from reference 8 unless otherwise specified.
*The incidences of these side effects are comparable to those of placebo group.
Fever: Is a transient febrile reaction with > 1°C elevation in body temperature and may last up to 48 hours.8 The fever usually occurs within 5 days of the first infusion of pamidronate and it may be accompanied by myalgia, nausea and headache.5 It is usually self-limiting and does not require treatment.8 If treatment is needed, acetaminophen may be used. Reducing the infusion rate is usually not helpful.5
Hypocalcemia: Symptomatic hypocalcemia is rare5 and the symptoms include abdominal cramps, confusion, muscle spasms, lethargy and irritability.6,21 Patients who have undergone thyroid surgery may be more prone to develop hypocalcemia after pamidronate therapy and should be monitored closely.8,21 Symptomatic hypocalcemia can be treated with oral or intravenous calcium supplement.8,21
Osteonecrosis of the jaw (ONJ) has been reported.18-20 Refer to Bisphosphonates and Osteonecrosis of the Jaw in the Oral/Dental Care section of the Cancer Management Guidelines for more detailed information.
INTERACTIONS:
AGENT |
EFFECT |
MECHANISM |
MANAGEMENT |
|
calcium- or vitamin D-containing preparations6 |
may antagonize the effect of pamidronate in the treatment of hypercalcemia |
additive |
avoid concurrent therapy |
SOLUTION PREPARATION AND COMPATIBILITY:
For basic information on solution preparation and compatibility, see Chemotherapy Chart in Appendix.
Injection: 30 mg, 60 mg and 90 mg vials; (as anhydrous pamidronate disodium); Preservative-free.8 Store at room temperature.6
Reconstitute each 30 mg, 60 mg and 90 mg vial with 10 mL of SWI to yield pamidronate concentrations of 3 mg/mL, 6 mg/mL and 9 mg/mL, respectively. Reconstituted solution is stable for 24 hours at room temperature.8
Diluted solution for infusion: Must be further diluted with NS or D5W to concentrations less than or equal to 0.36 mg/mL. Diluted solution should be used within 24 hours from the initial reconstitution when stored at room temperature.8
Compatibility: It is recommended that pamidronate not be mixed with calcium-containing infusion solutions, such as Ringer’s solution.8
PARENTERAL ADMINISTRATION:
|
BCCA administration standard noted in bold, italics |
|
Subcutaneous |
no information found |
|
Intramuscular |
no information found |
|
Direct intravenous |
not recommended since local reaction and thrombophlebitis may result from high local concentrations8 |
Intermittent infusion |
in 250 mL NS over 1 hour22-24
can also be given over 2-4 hours8,13,14 |
|
Continuous infusion |
over 24 hours6,25 |
|
Intraperitoneal |
no information found |
|
Intrapleural |
no information found |
|
Intrathecal |
no information found |
|
Intra-arterial |
no information found |
|
Intravesical |
no information found |
DOSAGE GUIDELINES:
Refer to protocol by which patient is being treated.
Adults:
|
|
|
BCCA usual dose noted in bold, italics |
|
|
Cycle Length: |
|
|
Intravenous: |
3-6 weeks8,13,14,26: |
90 mg IV for one dose on day 1
|
|
for bone loss |
12 weeks12: |
60 mg IV for one dose on day 1 |
|
|
Dosage guidelines for tumour-induced hypercalcemia8: |
|
|
initial serum calcium level (mmol/L) |
total pamidronate dose (mg) |
|
up to 3.0 |
30 |
|
3.0-3.5 |
30 or 60 |
|
3.5-4.0 |
60 or 90 |
|
>4.0 |
90 |
|
|
The total dose for a treatment course may be given as a single infusion or in multiple infusions spread over 2-4 consecutive days. The
maximum dose of pamidronate per treatment course is 90 mg regardless of initial or repeat treatment courses. Higher doses have not been associated with increased clinical effect. The dose ranges in the above table apply for both corrected and uncorrected serum calcium levels. The corrected serum calcium level can be calculated using the following equation:
cCa = tCa + (0.02 x [40-ALB])
where:
cCa = corrected serum calcium level (mmol/L)
tCa = measured total serum calcium level (mmol/L)
ALB = measured albumin level (g/L)
Decreases in serum calcium levels are generally observed within 24-48 hours after drug administration, with maximum lowering occurring by 3-7 days. If hypercalcemia recurs, or if serum calcium does not decrease within 2 days, repeat infusions of pamidronate may be given, according to the above dosage guidelines.8
|
|
Dosage in renal failure: |
No adjustment is required when the recommended dose schedule is used. However, a maximum infusion rate of 22.5 mg/h is recommended in patients with renal dysfunction.8,27 Moreover, there is limited experience with pamidronate in patients with serum creatinine > 440 mmol/L and caution should be used.8 |
|
|
|
|
|
Dosage in hepatic failure: |
no adjustment required8 |
|
|
|
|
|
Dosage in dialysis |
no information found |
|
|
|
|
Children:
|
|
|
|
intravenous: |
1-2 mg/kg IV over 3-24 hours has been used for tumour-induced hypercalcemia28 |
REFERENCES:
1. Health Canada Therapeutic Products Programme. Notices of Compliance (NOC)-Drugs. Available from http://www.hc-sc.gc.ca/hpb-dgps/therapeutic/htmleng/noc-drugs.html. Accessed 09 January, 2001.
2. Health Canada Therapeutic Products Programme. Patent register. Available from http://www.hc-sc.gc.ca/hpb-dgps/therapeut/htmleng/patents.html. Accessed 09 January, 2001.
3. Lipton A. Aredia: the once-monthly infusion for the treatment of bone metastases. Current Opinion in Oncology 1998;10(Suppl 1):S1-5.
4. Fleisch H. Bisphosphonates. Pharmacology and use in the treatment of tumour-induced hypercalcaemic and metastatic bone disease. Drugs 1991;42(6):919-44.
5. Coukell AJ, Markham A. Pamidronate. A review of its use in the management of osteolytic bone metastases, tumour-induced hypercalcaemia and Paget's disease of bone. Drugs & Aging 1998;12(2):149-68.
6. USP DI. Volume I. Drug information for the health care professional. 20th ed. Englewood: Micromedex, Inc.; 2000. p. 2368-70.
7. Brincker H, Westin J, Abildgaard N, et al. Failure of oral pamidronate to reduce skeletal morbidity in multiple myeloma: a double-blind placebo-controlled trial. Danish-Swedish co-operative study group. British Journal of Haematology 1998;101(2):280-6.
8. Novartis Pharmaceuticals Canada Inc. Aredia product monograph. Laval, Quebec; 30 July 1999.
9. Purohit OP, Radstone CR, Anthony C, et al. A randomised double-blind comparison of intravenous pamidronate and clodronate in the hypercalcaemia of malignancy. British Journal of Cancer 1995;72(5):1289-93.
10. Watters J, Gerrand G, Dodwell D. The management of malignant hypercalcaemia. Drugs 1996;52(6):837-48.
11. Chisholm MA, Mulloy AL, Taylor AT. Acute management of cancer-related hypercalcemia. Annals of Pharmacotherapy 1996;30(5):507-13.
12. Smith MR, McGovern FJ, Zietman AL, et al. Pamidronate to prevent bone loss during androgen-deprivation therapy for prostate cancer. New England Journal of Medicine 2001;345(13):948-55.
13. Berenson JR, Lichtenstein A, Porter L, et al. Long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. Myeloma Aredia Study Group [see comments]. J Clin Oncol 1998;16(2):593-602.
14. Hortobagyi GN, Theriault RL, Lipton A, et al. Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate. Protocol 19 Aredia Breast Cancer Study Group. J Clin Oncol 1998;16(6):2038-44.
15. Theriault RL, Lipton A, Hortobagyi GN, et al. Pamidronate reduces skeletal morbidity in women with advanced breast cancer and lytic bone lesions: a randomized, placebo-controlled trial. Protocol 18 Aredia Breast Cancer Study Group. J Clin Oncol 1999;17(3):846-54.
16. Lipton A, Theriault RL, Hortobagyi GN, et al. Pamidronate prevents skeletal complications and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials. Cancer 2000;88(5):1082-90.
17. Bloomfield DJ. Should bisphosphonates be part of the standard therapy of patients with multiple myeloma or bone metastases from other cancers? An evidence-based review [see comments]. J Clin Oncol 1998;16(3):1218-25.
18. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003;61(9):1115-7.
19. Carter GD, Goss AN. Bisphosphonates and avascular necrosis of the jaws. Aust Dent J 2003;48(4):268.
20. Novartis Pharmaceuticals Corporation. Updated safety: possible relationship of Aredia (pamidronate sodium) and/or Zometa (zoledronic acid) with osteonecrosis of the jaw. Dorval, Quebec; 5 November 2004.
21. Sims EC, Rogers PB, Besser GM, et al. Severe prolonged hypocalcaemia following pamidronate for malignant hypercalcaemia. Clinical Oncology (Royal College of Radiologists) 1998;10(6):407-9.
22. Vilimovskij A, Thuerlimann B, Berenson JR, et al. Renal safety and tolerability of 90mg of aredia (pamidronate) administered as an intravenous 1 hour infusion: preliminary results. Proc Am Soc Clin Oncol 1999;18:576a (abstract 2223).
23. Tyrrell CJ, Collinson M, Madsen EL, et al. Intravenous pamidronate: infusion rate and safety. Annals of Oncology 1994;5(Suppl 7):S27-9.
24. Tyrrell CJ. Role of pamidronate in the management of bone metastases from breast cancer: results of a non-comparative multicenter phase II trial. Aredia Multinational Cooperative Group. Annals of Oncology 1994;5(Suppl 7):S37-40.
25. Machado CE, Flombaum CD. Safety of pamidronate in patients with renal failure and hypercalcemia. Clin Nephrol 1996;45(3):175-9.
26. B.C. Cancer Agency Multiple Myeloma Tumour Group. BCCA protocol summary for treatment of multiple myeloma with pamidronate (MYPAM). Vancouver, British Columbia: BC Cancer Agency; 11 December 2000.
27. Berenson JR, Rosen L, Vescio R, et al. Pharmacokinetics of pamidronate disodium in patients with cancer with normal or impaired renal function. Journal of Clinical Pharmacology 1997;37(4):285-90.
28. Young G, Shende A. Use of pamidronate in the management of acute cancer-related hypercalcemia in children [see comments]. Medical & Pediatric Oncology 1998;30(2):117-21.