Pharmacologic class: Bisphosphonate, hypocalcemic
Therapeutic class: Bone resorption inhibitor
Pregnancy risk category C
Inhibits normal and abnormal bone resorption and decreases calcium levels
Injection: 30 mg/vial, 90 mg/vial
⊘Indications and dosages
➣ Hypercalcemia caused by cancer
Adults: For moderate hypercalcemia, 60 to 90 mg as a single-dose I.V. infusion over 2 to 24 hours. For severe hypercalcemia, 90 mg as a single-dose I.V. infusion over 2 to 24 hours.
➣ Osteolytic lesions caused by multiple myeloma
Adults: 90 mg I.V. as a 4-hour infusion q month
➣ Osteolytic bone metastases of breast cancer
Adults: 90 mg I.V. as a 2-hour infusion q 3 to 4 weeks
➣ Paget's disease
Adults: 30 mg I.V. daily as a 4-hour infusion for 3 days
• Hypersensitivity to drug, its components, or other bisphosphonates
Use cautiously in:
• renal impairment
• pregnant or breastfeeding patients
• children (safety not established).
• Hydrate patient with saline solution as needed before starting therapy.
• Because of risk of renal failure, give no more than 90 mg in single doses.
☞ Reconstitute vial using 10 ml of sterile water for injection. When completely dissolved, dilute in 250 to 1,000 ml of half-normal or normal saline solution or dextrose 5% in water.
☞ Don't mix with solutions containing calcium, such as lactated Ringer's solution.
• Administer in I.V. line separate from all other drugs and fluids.
CNS: anxiety, headache, insomnia, psychosis, drowsiness, weakness
CV: hypertension, syncope, tachycardia, atrial flutter, arrhythmias, heart failure
GI: nausea, vomiting, diarrhea, abdominal pain, constipation, dyspepsia, stomatitis, anorexia, GI hemorrhage
GU: urinary tract infection
Hematologic: anemia, neutropenia, leukopenia, granulocytopenia, throm-bocytopenia
Musculoskeletal: bone pain, joint pain, myalgia
Respiratory: crackles, coughing, dyspnea, upper respiratory infection, pleural effusion
Other: fever, generalized pain, injection site reaction
Drug-diagnostic tests.Creatinine: increased level
Electrolytes, hemoglobin, magnesium, phosphorus, platelets, potassium, red blood cells, white blood cells: decreased levels
• Monitor hydration status carefully.
• Monitor vital signs and ECG. Evaluate cardiovascular and respiratory status closely.
• Assess hematologic studies and creatinine level before each treatment course.
• Assess electrolyte levels, especially calcium, magnesium, and phosphorus.
• Closely monitor fluid intake and output. Watch for signs and symptoms of urinary tract infection.
• Instruct patient to weigh himself regularly and report sudden gains.
☞ Advise patient to promptly report significant respiratory problems, peripheral edema, or GI bleeding.
☞ Inform patient that drug lowers resistance to some infections. Tell him to immediately report fever and other signs and symptoms of infection.
• Explain importance of undergoing laboratory tests before, during, and after therapy.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, cognition, and alertness.
• Tell patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the tests mentioned above.
ClassificationTherapeutic: bone resorption inhibitors
Time/action profile (effect on serum calcium)
|IV||24 hr||7 days||unknown|
Adverse Reactions/Side Effects
Central nervous system
Ear, Eye, Nose, Throat
- blurred vision
- eye pain/inflammation
- nausea (most frequent)
- abdominal pain
Fluid and Electrolyte
- hypocalcemia (most frequent)
- hypokalemia (most frequent)
- hypomagnesemia (most frequent)
- hypophosphatemia (most frequent)
- fluid overload
- leukopenia (most frequent)
- phlebitis at injection site (most frequent)
- muscle stiffness (most frequent)
- musculoskeletal pain (most frequent)
- femur fractures
- osteonecrosis (primarily of jaw)
- fever (most frequent)
- generalized pain (most frequent)
Drug-Drug interactionHypokalemia 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/DosageSingle doses should not exceed 90 mgHypercalcemia of Malignancy
Availability (generic available)
- 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.
Potential Nursing DiagnosesAcute pain (Indications, Side Effects)
Risk for injury (Indications)
- 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.
- Intravenous: 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: Diluent: Dilute further in 1000 mL of 0.45% NaCl, 0.9% NaCl, or D5W. Solution is stable for 24 hr at room temperature.
- Rate: Administer 60-mg infusion over at least 4 hr and 90-mg infusion over 24 hr.
- Multiple Myeloma: Diluent: Dilute reconstituted solution in 500 mL of 0.45% NaCl, 0.9% NaCl, or D5W.
- 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, aminiophylline, amphotericin B lipid complex, amphotericin B liposome, ampillicin, ampicillin/sulbactam, anidulafungin, argatroban, atracurium, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, 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, dolasetron, dopamine, doxacurium, doxorubicin, doxorubicin liposomal, doxycycline, droperidol, enelaprilat, 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, mechlorethamine, melphalan, meperidine, meropenem, mesna, metaraminol, methotrexate, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxytocin, paclitaxel, palonosetron, pancuronium, pemetrexed, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, piperacillin/tazobactam, potassium acetate, potassium chloride, potassium phosphates, procainamide, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, rocuronium, sodium acetate, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, topotecan, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine
- Y-Site Incompatibility: amphotericin B colloidal, caspofungin, dantrolene, diazepam, leucovorin, phenytoin
- Additive Incompatibility: Calcium-containing solutions, such as Ringer’s solution.
- 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.
- Lowered serum calcium levels.
- Decreased pain from lytic lesions.