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Cancer Type: Breast, Central Nervous System, Endocrine, Gastrointestinal, Genitourinary, Gynecologic, Head and Neck, Hematologic, Lung, Sarcoma, Skin, Unknown Primary  Intent: Supportive Care, Palliative
Regimen Category: Evidence-Informed
A - Regimen Name

Zoledronic acid

Disease Site
Central Nervous System
Head and Neck
Unknown Primary

Supportive Care

Regimen Category
Evidence-Informed :

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.

Rationale and Uses

Treatment of tumour-induced hypercalcemia (corrected serum calcium ≥ 3 mmol/L) following adequate saline rehydration.

B - Drug Regimen

zoledronic acid
4 mg IV Day 1
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C - Cycle Frequency

Single dose. Allow a minimum of 7 days prior to retreatment.

D - Premedication and Supportive Measures

Other Supportive Care:

All patients should be adequately hydrated.

E - Dose Modifications

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.

Dosage with toxicity

Dosage in myelosuppression:  No dosage adjustment required

Non-hematologic Toxicity
Atypical fractures of the femur
Hold if suspected.  Consider discontinuing if confirmed. 
Ocular symptoms other than uncomplicated conjunctivitis
Refer to ophthalmologist; consider discontinuing.
Osteonecrosis of the jaw, other sites
For ONJ, refer to dentist or dental surgeon; consider hold or discontinue.
Severe musculoskeletal pain


Acquired Fanconi syndrome Discontinue

Increased creatinine:

> 400 µmol/L with tumour-induced hypercalcemia


Hold until recovered to within 10% of baseline* (see table below for renal impairment at baseline)

*normal baseline creatinine is defined as < 123 μmol/L

Hepatic Impairment

There are no pharmacokinetic data in patients with impaired liver function.  Zoledronic acid is not cleared by the liver; therefore, impaired liver function may not affect the pharmacokinetics of zoledronic acid.

Renal Impairment

Renal function

Zoledronic acid dose (mg)

Creatinine Clearance (mL/min)

> 400 µmol/L with tumour-induced hypercalcemia

< 30
Do not treat

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.



Not recommended for use in children. Bone development was affected in growing animals.

F - Adverse Effects

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

  • Nausea, vomiting
  • Fatigue, flu-like symptoms
  • Cough, dyspnea (may be severe)
  • Diarrhea
  • Musculoskeletal pain (may be severe)
  • Edema
  • Headache
  • Dizziness
  • Nephrotoxicity (may be severe)
  • Weight loss
  • Paresthesia
  • Depression
  • Abnormal electrolytes
  • Conjunctivitis
  • Atypical fractures of the femur
  • Atrial fibrillation, arrhythmia
  • Osteonecrosis of the jaw (ONJ) or other sites
  • Hypersensitivity
  • Eye disorders
  • Acquired Fanconi syndrome
G - Interactions

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
  • Caution with antiangiogenic drugs (e.g. sunitinib, bevacizumab) given increased risk of ONJ
H - Drug Administration and Special Precautions

Refer to zoledronic acid drug monograph(s) for additional details



  • 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 100mL 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.


  • 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


  • The use of zoledronic acid with other nephrotoxins (cisplatin, NSAIDS, aminoglycosides, etc.), 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.
I - Recommended Clinical Monitoring

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; undergo invasive dental procedures, if needed, before starting bisphosphonate treatment; regular check-ups
  • Clinical toxicity assessment for flu-like syndrome, dental, musculoskeletal, signs of acquired Fanconi syndrome, and ocular symptoms; At each visit
  • 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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J - Administrative Information

Approximate Patient Visit
0.5 hour
Pharmacy Workload (average time per visit)
16 minutes
Nursing Workload (average time per visit)
35 minutes
K - References

Major P, Lortholary A, Hon J, et al.  Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clinical trials.  J Clin Oncol 2001;19(2):558. 

Zoledronic acid drug monograph, Cancer Care Ontario.

January 2018 ST-QBP regimen; new addition to Drug Formulary website

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M - Disclaimer

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.
CCO and the Formulary’s content providers shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the Formulary or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the Formulary does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person’s use of the information in the Formulary.