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.
ZOLE
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.
For the treatment patients with renal cell cancer and bone metastases.
Other Supportive Care:
All patients, especially those with hypercalcemia, should be adequately hydrated. Calcium and Vitamin D supplements should be considered in patients who have normal calcium levels with no history of hypercalcemia. (Refer to zoledronic acid monograph).
Doses should be modified according to the protocol by which the patient is being treated. The following recommendations have been adapted from clinical trials or product monographs and could be considered.
Do not administer to patients with open soft tissue lesions in the mouth.
Hypocalcemia must be corrected before administering zoledronic acid.
Dosage with toxicity
Dosage in myelosuppression: No dosage adjustment required
Toxicity
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Action
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Atypical fractures of the femur
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Hold if suspected. Consider discontinuing if confirmed.
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Ocular symptoms other than uncomplicated conjunctivitis
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Refer to ophthalmologist; consider discontinuing
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Osteonecrosis of the jaw, other sites
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For ONJ, refer to dentist or dental surgeon; consider hold or discontinue
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Severe musculoskeletal pain
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Discontinue |
Acquired Fanconi syndrome | Discontinue |
Increased creatinine:
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Hold until recovered to within 10% of baseline (see table for dose adjustment for renal impairment at baseline) |
Hepatic Impairment
There are no pharmacokinetic data in patients with hepatic impairment. Zoledronic acid is not cleared by the liver.
Renal Impairment
Starting Dose |
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Creatinine
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Creatinine Clearance (mL/min)
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For bone metastases |
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> 60
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4 mg
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50 - 60
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3.5 mg
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40 - 49
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3.3 mg
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30 - 39
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3 mg
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> 265 µmol/L |
Or
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<30
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Do not treat
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Dosage in the Elderly
Similar efficacy and safety as compared to younger patients, but use with caution due to cardiac risks or renal function impairment.
Refer to zoledronic acid drug monograph(s) for additional details of adverse effects
Common (25-49%) |
Less common (10-24%) |
Uncommon (< 10%), but may be severe or life-threatening |
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Refer to zoledronic acid drug monograph(s) for additional details
- Caution and monitor with drugs that cause hypocalcemia (e.g. aminoglycosides, loop diuretics, calcitonin)
- Caution and monitor with drugs that cause renal dysfunction (e.g. NSAIDs, ACE inhibitors)
- Avoid in patients with hypersensitivity to ASA given possible increased risk of bronchospasm (theoretical)
- Caution with antiangiogenic drugs (e.g. sunitinib, bevacizumab) given increased risk of ONJ
Refer to zoledronic acid drug monograph(s) for additional details
Administration:
- Do not infuse over a duration of less than 15 minutes.
- All patients should be adequately hydrated prior to and after administration of zoledronic acid, but overhydration should be avoided.
- Mix with 100 mL solution (D5W or NS) and infuse over ≥ 15 minutes.
- Do not mix with calcium or other divalent cation-containing solutions.
- Compatible with PVC, glass, polyethylene and polypropylene containers or infusion lines.
- Should be administered as a single intravenous solution in a line separate from all other drugs.
- Store unopened vials at room temperature.
Contraindications:
- Patients who have a hypersensitivity to this drug or any of its components, or other bisphosphonates
- Patients with non-corrected hypocalcemia at time of infusion or severe renal failure
- Zoledronic acid should not be given together with other bisphosphonates since the combined effects of these agents are unknown
Other Warnings/Precautions:
- The use of zoledronic acid with other nephrotoxins, doses > 4mg, infusion duration < 15 minutes and previous bisphosphonate use are associated with an increased risk of renal failure.
- Use with caution in patients with cardiac failure, especially in the elderly.
- Use with caution in patients with risk factors for ONJ, including patients receiving concomitant chemotherapy or anti-angiogenic agents; patients should be advised to avoid invasive dental procedures while receiving zoledronic acid.
- Caution in patients who have had thyroid surgery since they are susceptible to hypocalcaemia due to relative hypoparathyroidism.
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
- Renal function tests (serum creatinine and BUN); baseline, before each dose and during therapy, as indicated
- Calcium, corrected levels (including serum albumin), electrolytes (including phosphate, magnesium); baseline, before each dose and during therapy, as indicated
- CBC; baseline and as clinically indicated
- Comprehensive dental evaluation of both hard and soft tissues before starting bisphosphonate treatment; undergo invasive dental procedures, if needed, before starting bisphosphonate treatment; regular check-ups
- Clinical toxicity assessment for flu-like syndrome, dental, signs of acquired Fanconi syndrome, musculoskeletal and ocular symptoms; at each visit
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Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
Suggested Clinical Monitoring
- Ophthalmology examination with ocular symptoms; as clinically indicated
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Lipton A, Zheng M, Seaman J. Zoledronic acid delays the onset of skeletal-related events and progression of skeletal disease in patients with advanced renal cell carcinoma. Cancer 2003;98(5):962-9.
Rosen LS, Gordon D, Tchekmedyian S, et al. Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with lung cancer and other solid tumors: a phase III, double-blind, randomized trial--the zoledronic acid lung cancer and other solid tumors study group. J Clin Oncol 2003;21(16):3150-7.
Zoledronic acid drug monograph, Cancer Care Ontario.
April 2023 removed NDFP form
The skeletal-related event and skeletal morbidity rates were significantly less for patients who received zoledronic acid compared to placebo. Time to first skeletal-related event and time-to-progression of bone lesions were also significantly better in the zoledronic acid arm.
In a small retrospective review of 166 cancer patients, of whom 78 received zoledronic acid, osteonecrosis of the jaw (ONJ) developed in one patient with renal cell carcinoma who received sunitinib and zoledronic acid concurrently. A significantly higher incidence of ONJ was observed in patients with cancer receiving bisphosphonates with antiangiogenic agents versus bisphosphonates treatment alone (16% vs 1.1%, p=0.008).
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.
While care has been taken in the preparation of the information contained in the Formulary, 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.
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