PAMIDRONATE: PAEDIATRIC RHEUMATOLOGY PROTOCOL
Introduction
Bisphosphonates have a phosphorus or carbon/phosphorus structure that is adsorbed onto
hydroxyapatite to inhibit bone resorption. They increase bone mineral accretion and reduce bone
turnover and are valuable in metabolic and inflammatory bone diseases of childhood. The drug of
choice at present is Pamidronate, given intravenously (IV) in 3-4 monthly courses. Risedronate
and other oral preparations are widely used in adults but have yet to be fully evaluated in
paediatrics.
Indications

In Paediatric Rheumatology it is mainly used for:
 Chronic recurrent multifocal osteomyelitis (CRMO)
 Bone disease from systemic illness and prolonged steroid use
 Significant soft tissue calcification without bony abnormality - eg:
dermatomyositis
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Other conditions where Pamidronate might be used are:
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Bone matrix abnormalities - eg: osteogenesis imperfecta, Gaucher’s
Disease,hypophosphatasia and fibrous dysplasia.
Ongoing, recurrent fractures
Bone pain with significantly reduced bone mineralisation (ie DEXA
and after correcting for age, height, weight, pubertal stage)
Acute management of hypercalcaemia - eg: in malignancy.
Idiopathic juvenile osteoporosis
Investigations Before Starting Treatment
If diagnosis of osteopenia not fully evaluated see management guideline for a child with
osteopenia
Otherwise check
 bone profile (calcium, phosphate and alkaline phosphatase)
 vitamin D status – if <50 pre-treat with colecalciferol (See OUH guideline)
o 3000units/ml colecalciferol solution daily for 2 months
 Age 1-12 months: 3000 units/day
 Age 12 months - 12 years: 6000 units/day
 Age 12-18 years: 9000 units/day
o Vitamin D had been difficult to obtain in treatment doses, but is now prescribable
as Colecalciferol Liquid 3,000 units/ml. Tablets or capsules of 400, 1,000, 10,000,
20,000 units are also prescribable. The same effect may be achieved by
multiplying the dose by seven and giving it weekly. In older children, especially if
compliance is a concern, some recommend a single dose (multiply daily dose by
30).
 Dental check-up – if possible avoid dental interventions while on Pamidronate due to risk
of jaw osteonecrosis.
K. Bailey/A. Kavirayani/E. Parsons/R. Etherton. Version 4 – revised January 2016.
Paediatric Endocrinology protocol.
Based on Oxford
Treatment Protocol
This protocol is for guidance and may need modification depending on the response to treatment
or side effects. There is now good evidence that cyclic administration of Pamidronate will improve
bone mineralisation in children.
Dosage:
Each cycle consists of an IV infusion of Pamidronate daily for two consecutive days:
Age (years) Dosage Frequency
Age (years)
<2
2-3
>3
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Dosage
0.75mg/kg/day for 2 days
1.125mg/kg/day for 2 days
1.5mg/kg/day for 2 days
(max dose 90mg)
Frequency
2 monthly
3 monthly
3 monthly
Pamidronate should be diluted in 0.9% Sodium Chloride (concentration not to exceed
60mg in 250ml) and infused over 2 hours. See preparation of infusion below.
The second infusion may be started 20 hours after the start of the first infusion.
Further doses may be required on a 3 monthly basis (speak with paediatric rheumatology
team).
mg of Pamidronate to be Amount of 0.9% Sodium Infusion rate over 2 hours
infused in one day (mg/day) Chloride to add to obtain a (ml/hr)
based on patient weight
total infusion volume of:
0-5 mg/day
50 mls
25 mls/hr
5.1-15 mg/day
100 mls
50 mls/hr
15.1-60 mg/day
250 mls
125 mls/hr
60.1-90 mg/day
500 mls
250 mls/hr
Monitoring:
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Before the first infusion of each cycle: FBC, U+Es, LFTs, CRP, ESR.
If previously abnormal, it may be necessary to check bone profile prior to infusion cycle.
A decision about continuing therapy after the first year will be made when the response to
the therapy has been evaluated.
Depending on indication, treatment may be extended to 2 years with further DEXA for
monitoring (eg Osteogenesis imperfect)
Side Effects:
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Flu like symptoms associated with pyrexia and back and/or limb pain. These can be
treated with paracetamol. NSAIDs i.e. Ibuprofen or naproxen can be used unless any
other contraindication. These usually only occur during the first cycle of treatment.
Occasional transient hypocalcaemia
K. Bailey/A. Kavirayani/E. Parsons/R. Etherton. Version 4 – revised January 2016.
Paediatric Endocrinology protocol.
Based on Oxford
Contacts for Paediatric Rheumatology Team
1. Paediatric rheumatology advanced nurse practitioners 01865 737341
cnspaedrheum@ouh.nhs.uk
2. Dr Kathy Bailey (Consultant Paediatric Rheumatologist) kathryn.bailey@ouh.nhs.uk or via
secretary 01865 738026
3. Dr Akhila Kavirayani (Locum Consultant Paediatric Rheumatologist)
Akhila.kavirayani@ouh.nhs.uk or via secretary 01865 738026
Out of hours – Contact can be made with the on-call Doctor for rheumatology via switchboard
at the NOC 01865 741155
K. Bailey/A. Kavirayani/E. Parsons/R. Etherton. Version 4 – revised January 2016.
Paediatric Endocrinology protocol.
Based on Oxford