Pamidronate hypercalcaemia

The treatment of Mrs CR s hypercalcaemia is urgent and requires immediate administration of bisphosphonate therapy, the first choice therapy in cases of severe hypercalcaemia. Currently four bisphosphonates are available in the UK for the treatment of malignant hypercalcaemia - sodium clodronate, disodium pamidronate, zoledronic acid and ibandronic acid. The choice of which bisphosphonate to recommend will depend on which one is on the local hospital formulary. 

Bisphosphonates (see later). Pamidronate is infused according to the schedule in Table 38.1 it is active in a wide variety of hypercalcaemic disorders. Fall in serum calcium begins in 1-2 d, reaches a nadir in 5-6 d and lasts 20-30 d. Etidronate may be given i.v. in hypercalcaemia of malignant disease. It acts in 1-2 d and a dose lasts 3 weeks it may also provide benefit for neoplastic metastatic disease in bone. Clodronate (oral or i.v.) or zoledonic acid (i.v) are alternatives. 

TABLE 38.1 Treatment of hypercalcaemia with disodium pamidronate ... 

Uses. Three bisphosphonates (alendronate, etidronate, risedronate) are currently licensed in the UK for the treatment of osteoporosis (zoledronate is also effective), and the others are used in Paget s disease of bone, and hypercalcaemia due to cancer (pamidronate, clodronate, zoledronate). Bisphosphonates may also provide benefit for neoplastic disease that has spread to bone evidence indicates that clodronate by mouth and pamidronate i.v. are effective in the secondary prevention of bone metastases due to multiple myeloma and breast cancer. 

De Schepper J, de Pont S, Smitz J, De Coster D, Schots R, Otten J. Metabolic disturbances after a single dose of 30 mg pamidronate for leukaemia-associated hypercalcaemia in a 11-year-old boy. Eur J Pediatr 1999 158(9) 765-6. 

Bisphosphonates are widely used for the prevention and treatment of osteopenia and osteoporosis and for the reduction of skeletal complications in patients with malignant bone disease. Several oral bisphosphonates, including alendronate, risedronate, and ibandronate, are approved worldwide for the treatment of osteoporosis in postmenopausal women, as are intravenous (i.v.) formulations of ibandronate (3 mg quarterly) and zoledronic acid (5 mg annually). Several i.v. bisphosphonates are available for the treatment of the skeletal complications that frequently occur in malignant disease, such as hypercalcaemia of malignancy (HCM), multiple myeloma, and bone metastases associated with solid tumours. Pamidronate is approved worldwide for the treatment of HCM, multiple myeloma, and breast cancer bone metastases. Although not registered for oncology indications in the United States, i.v. ibandronate is widely available elsewhere for HCM and breast cancer bone metastases. 

AE = Adverse event BC = Breast cancer CLOD = Clodronate EHDP = Etidronate HCM = Hypercalcaemia of malignancy IBN = Ibandronate i.v = Intravenous LC = Lung cancer MM = Multiple myeloma OST = Other solid tumours (renal, head and neck, thyroid, other) PDB = Paget s disease of bone PAM = Pamidronate PC = Prostatecancer PLA = Placebo PMO = Postmenopausal osteoporosis RIS = Risedronate ZOL = Zoledronicacid. 

Purohit OP, Radstone CR, Anthony C, Kanis JA, Coleman RE. A randomised double-blind comparison of intravenous pamidronate and clodronate in the hypercalcaemia of malignancy. Br J Cancer 1995 72 1289-1293. 

Selby, P. L., Davies, M., Marks, J. S., Mawer, E. B. 1995. Vitamin D intoxication causes hypercalcaemia by increased bone resorption which responds to pamidronate. Clin Endocrinol (Oxf), 43 531-6. 

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