Pamidronate clinical toxicity

The bisphosphonates are analogs of pyrophosphate in which the P-O-P bond has been replaced with a nonhydrolyzable P-C-P bond (Figure 42-4). Etidronate, pamidronate, and alendronate have now been joined by risedronate, tiludronate, ibandronate, and zoledronate for clinical use. The bisphosphonates owe at least part of their clinical usefulness and toxicity to their ability to retard formation and dissolution of hydroxyapatite crystals within and outside the skeletal system. They localize to regions of bone resorption and so exert their greatest effects on osteoclasts. However, the exact mechanism by which they selectively inhibit bone resorption is not clear. 

In comparison with the results obtained with earlier bisphosphonates, clinical trials with the nitrogen-containing bisphosphonate pamidronate in more than 1, 300 patients with cancer have reported greater efficacy without a concomitant increase in renal toxicity. 

---