Drug Formulary information is intended for use by healthcare professionals. It is not intended to be medical advice. Some of the information, including information about funding for cancer drugs, does not apply to all patients. Cancer treatment plans are unique to each patient. If you are a patient, please speak with your healthcare team to understand how this information applies to you.
PMDR
Regimen is considered appropriate as part of the standard care of patients; meaningfully improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR). Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.
Prevention of skeletal events (pathologic fractures, bony pain, and radiation requirement) in patients with active myeloma, especially those with lytic lesions / osteoporosis/ osteopenia
| pamidronate | 90 mg | IV | Day 1 |
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Administer concurrently with first-line or salvage cytotoxic chemotherapy
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REPEAT EVERY 28 DAYS
In the absence of unacceptable toxicity
In the management of multiple myeloma, to reduce risk of osteonecrosis of the jaw after two years of treatment, consideration is given to either:
Discontinuing treatment in patients who have responded and who have stable bone metastases
OR
Decreasing frequency to every three months if the patient still needs active treatment
Not applicable
Other Supportive Care:
- All patients, especially those with hypercalcemia, should be adequately hydrated.
- Calcium and vitamin D supplements should be given to patients at risk of low serum calcium and who have no history of hypercalcemia.
Doses should be modified according to the protocol by which the patient is being treated.
Dosage with toxicity
Dosage in myelosuppression: No dosage adjustment required.
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Toxicity
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Action
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Osteonecrosis of jaw
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Refer patient to dentist or dental surgeon; consider hold or discontinue. |
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Atypical fractures of the femur |
Consider discontinuing
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Severe musculoskeletal pain
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Ocular symptoms other than uncomplicated conjunctivitis |
Refer to ophthalmologist; consider discontinuing. |
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Nephrotoxicity
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Hold until recovered to within 10% of baseline |
Hepatic Impairment
AUC is increased in mild to moderate hepatic impairment but not considered clinically relevant; no dosage adjustment is required. No data available in patients with severe hepatic dysfunction and so should be used with caution.
Renal Impairment
Patients with severe renal impairment (< 30mL/min) have 3 times higher pamidronate exposure than those with normal renal function.
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Baseline
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During Treatment
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Level
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Action
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Level/change
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Action
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Clcr > 90 mL/min
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No adjustment needed
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Creatinine ↑ of 44 µmol/L if normal baseline
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Hold until returns to within 10% of baseline
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Clcr 30-90 mL/min
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Do not exceed infusion rate of 22.5 mg/h |
Creatinine ↑ of 88 µmol/L if abnormal baseline
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Clcr < 30 mL/min
or
Creatinine
> 440 µmol/L (tumour induced hypercalcemia - TIH) or
> 180 µmol/L (myeloma)
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Only use for life-threatening hypercalcemia where the benefit exceeds risk |
Clcr < 30 mL/min
or
Creatinine
> 440 µmol/L (TIH) or
> 180 µmol/L (myeloma)
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Only use for life-threatening hypercalcemia where the benefit exceeds risk
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Refer to pamidronate drug monograph(s) for additional details of adverse effects.
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Common (25-49%) |
Less common (10-24%) |
Uncommon (< 10%), but may be severe or life-threatening |
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Refer to pamidronate drug monograph(s) for additional details.
Administration:
- Pamidronate must not be mixed with calcium-containing solutions (e.g., Ringer's solution).
- Pamidronate is generally mixed in 250-500mL solution (D5W or NS) and infused over 2-4 hours.
- According to the product monograph, it is recommended not to exceed 90 mg in 500 mL over 4 hours (i.e. 22.5 mg/h infusion rate) in multiple myeloma and tumour-induced hypercalcemia.
- Pamidronate must never be given as a bolus injection because of the risk of thrombophlebitis, severe local reactions and renal failure; it should always be diluted and administered as a slow IV infusion.
- All patients, especially those who are dehydrated or hypercalcemic, must be adequately rehydrated prior to treatment with pamidronate.
- Store unopened vials at room temperature (15-25°C). Protect vials from heat.
Contraindications:
- Patients with known or suspected hypersensitivity to pamidronate, or any of its components, or to other bisphosphonates
- Pregnant and/or breastfeeding women
Warnings/Precautions:
- Pamidronate should not be given together with other bisphosphonates to treat hypercalcemia, since the combined effects of these agents are unknown.
- Patients must be adequately hydrated throughout treatment, but special care should be taken in the elderly and patients with cardiac disease, to prevent fluid overload and cardiac failure.
- Avoid in patients with severe renal impairment, except in life-threatening cases of hypercalcemia.
- Use with caution in patients with risk factors for ONJ (see adverse effects description section).
- Patients should not drive, operate machinery or perform tasks that require alertness if they experience somnolence and/or dizziness after infusion.
Pregnancy/Lactation:
- Pamidronate is contraindicated in pregnancy. Adequate contraception should be used by both sexes during treatment, and for at least 6 months after the last dose (general recommendation).
- Breastfeeding is contraindicated.
- Fertility effects: Probable
Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph
Recommended Clinical Monitoring
- Dental examination with appropriate preventative dentistry should be considered prior to treatment. Regular dental check- ups. Avoid invasive dental surgeries while on treatment.
- Renal function tests; Baseline and at each visit
- Electrolytes, including corrected serum calcium, phosphates, magnesium, and serum albumin; Baseline and as clinically indicated
- Fluid balance (e.g. urine output, daily weights), especially in patients with pre-existing renal disease or risk of renal impairment; As clinically indicated
- Clinical toxicity assessment (including flu-like syndrome, hypersensitivity, hydration status, pain, dental, otic and ocular effects); At each visit
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Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
Suggested Clinical Monitoring
- CBC, in patients with anemia, leukopenia, or thrombocytopenia; Baseline and as clinically indicated
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Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma. N Engl J Med 1996;334:488-93.
Corso A, Varettoni M, Zappasodi P, et al. A different schedule of zoledronic acid can reduce the risk of the osteonecrosis of the jaw in patients with multiple myeloma. Leukemia 2007;21(7):1545-8.
Pamidronate drug monograph, Ontario Health (Cancer Care Ontario).
Tanvetyanon T, Stiff PJ. Management of the adverse effects associated with intravenous bisphosphonates. Annals of Oncology 2006;17:897–907.
January 2024 Modified Dosing and Administration guidelines sections
Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
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