Pamifos (Disodium Pamidronate)
Bisphosphonate — Intravenous Infusion for Bone-Related Conditions in Cancer
Pamifos contains disodium pamidronate, a potent bisphosphonate that inhibits bone breakdown. It is administered as a slow intravenous infusion to treat high blood calcium caused by cancer (tumour-induced hypercalcaemia), to reduce bone destruction from breast cancer that has spread to the skeleton, and to manage bone lesions in advanced multiple myeloma. This medication is given exclusively in hospital settings under physician supervision.
Quick Facts
Key Takeaways
- Pamifos is a bisphosphonate given by slow intravenous drip to reduce high calcium levels and protect bones damaged by cancer.
- It is used for tumour-induced hypercalcaemia, osteolytic bone metastases from breast cancer, and bone lesions in multiple myeloma.
- The most common side effects are flu-like symptoms and mild fever, which typically occur only with the first infusion and resolve within 24 hours.
- Kidney function must be monitored before each dose, and treatment should be paused if renal function deteriorates significantly.
- Patients should maintain good oral hygiene and have a dental check before starting treatment due to the risk of osteonecrosis of the jaw.
What Is Pamifos and What Is It Used For?
Pamifos belongs to the bisphosphonate class of medicines, a group of drugs that act primarily on bone metabolism by inhibiting the activity of osteoclasts — the cells responsible for breaking down bone tissue. The active substance, disodium pamidronate, binds strongly to hydroxyapatite crystals in bone, effectively slowing the rate at which bone is resorbed. This mechanism makes it particularly valuable in oncology, where malignant diseases frequently accelerate bone destruction and release excessive calcium into the bloodstream.
The medicine is supplied as a concentrated solution (3 mg/ml) that must be diluted before use and administered as a slow intravenous infusion. It is never taken orally or injected as a bolus. All infusions are performed under the supervision of a physician with appropriate monitoring equipment, typically in a hospital or specialised clinic setting.
Approved Indications
Pamifos is authorised for three primary clinical indications:
- Tumour-induced hypercalcaemia (TIH): Many cancers, particularly of the lung, breast, kidney, and blood, can cause dangerously elevated calcium levels in the blood. Left untreated, severe hypercalcaemia leads to confusion, cardiac arrhythmias, renal failure, and coma. Pamifos rapidly normalises serum calcium within 3–7 days in most patients by inhibiting osteoclastic bone resorption.
- Osteolytic bone metastases from breast cancer: When breast cancer spreads to the skeleton, it stimulates osteoclast activity, leading to painful bone destruction, pathological fractures, and further calcium release. Regular Pamifos infusions every 3–4 weeks significantly reduce skeletal complications and bone pain.
- Advanced multiple myeloma: This haematological malignancy of plasma cells frequently causes widespread osteolytic bone lesions. Pamifos at 90 mg every four weeks helps preserve bone integrity, reducing fractures and bone pain in patients with stage III disease.
Disodium pamidronate, the active ingredient in Pamifos, may also be approved for other conditions not listed here. Patients should always follow their physician’s instructions regarding off-label use. The World Health Organization (WHO) includes pamidronate among established bisphosphonates for managing malignancy-related bone disease, and the European Medicines Agency (EMA) has approved its use across the European Economic Area.
Pamifos is only administered to adult patients (18 years and older). Safety and efficacy in children and adolescents have not been established. The drug is always given in a healthcare facility with the capacity to monitor its clinical and biochemical effects.
What Should You Know Before Receiving Pamifos?
Contraindications
Pamifos must not be used in the following situations:
- Hypersensitivity: Known allergy to disodium pamidronate, other bisphosphonates (such as zoledronic acid, alendronate, or ibandronate), or any of the excipients in the formulation (sodium hydroxide, hydrochloric acid, water for injections).
- Breastfeeding: Pamidronate is contraindicated during breastfeeding as the drug may pass into breast milk and affect the nursing infant.
Warnings and Precautions
Before receiving Pamifos, it is essential to discuss the following conditions and situations with your treating physician:
- Kidney disease: Pamidronate is excreted through the kidneys and can itself impair renal function. Serum creatinine must be measured before each dose. Pamifos should not be given to patients with severe renal impairment (creatinine clearance <30 ml/min) except in life-threatening hypercalcaemia.
- Heart problems: Cardiac monitoring may be needed. Atrial fibrillation has been reported, though a causal relationship has not been established.
- Liver disease: No dose adjustment is needed for mild to moderate hepatic impairment. Pamifos has not been studied in severe liver disease.
- Low blood counts: Anaemia, thrombocytopenia (low platelets), and leukopenia (low white blood cells) have been reported. Blood counts should be monitored regularly.
- Thyroid surgery: Patients who have undergone thyroidectomy or parathyroidectomy may be more susceptible to hypocalcaemia.
- Salt-restricted diet: Though Pamifos contains less than 1 mmol (23 mg) sodium per vial, patients on strict sodium restriction should be informed.
- Concurrent nephrotoxic drugs: Other medications that can harm the kidneys should be used with caution alongside pamidronate.
Cases of osteonecrosis of the jaw have been reported in cancer patients treated with bisphosphonates including Pamifos. Symptoms include jaw pain, swelling, non-healing sores in the mouth, numbness, a feeling of heaviness, or loose teeth. Risk factors include concurrent chemotherapy, radiotherapy, corticosteroid use, dental surgery, poor oral hygiene, pre-existing dental disease, and smoking. A dental examination is recommended before starting treatment. Avoid dental surgery during treatment. Report any oral symptoms immediately to your doctor and dentist.
Pregnancy and Breastfeeding
Women who are pregnant, suspect they may be pregnant, or are planning a pregnancy must inform their doctor before receiving Pamifos. Bisphosphonates are incorporated into the bone matrix and may be slowly released over weeks to years. The potential risk to a developing foetus is therefore not limited to the period of drug administration. Animal reproductive studies have shown adverse effects, and pamidronate should be used during pregnancy only when the benefit clearly outweighs the potential risk.
Breastfeeding is contraindicated during Pamifos treatment. It is unknown whether pamidronate is excreted in human breast milk, but given the potential for serious adverse reactions in nursing infants, breastfeeding must be discontinued before treatment begins.
Driving and Operating Machinery
Patients should not drive or operate machinery if they experience drowsiness, dizziness, or other side effects that may impair their ability to perform these activities safely after an infusion of Pamifos. Each individual is responsible for assessing their own fitness to drive, and should discuss any concerns with their healthcare provider.
How Does Pamifos Interact with Other Drugs?
Drug interactions with pamidronate can be clinically significant and may affect both the efficacy and safety of treatment. Because Pamifos is administered intravenously in a clinical setting, interactions are typically managed by the treating physician, but patients must provide a complete list of all current medications.
Major Interactions
The following drug categories require particular caution when co-administered with Pamifos:
| Drug / Class | Interaction | Clinical Significance |
|---|---|---|
| Calcitonin | Additive calcium-lowering effect; risk of severe hypocalcaemia | High — monitor serum calcium closely |
| Other bisphosphonates | Additive effect on bone resorption inhibition and renal toxicity | High — avoid concurrent use |
| Nephrotoxic drugs (aminoglycosides, NSAIDs, cisplatin, contrast agents) | Increased risk of renal impairment | High — monitor renal function |
| Thalidomide | Increased risk of renal impairment in multiple myeloma patients | Moderate — dose adjustments may be needed |
Minor Interactions and Incompatibilities
Pamifos must not be mixed with calcium-containing intravenous solutions (such as Ringer’s lactate), as pamidronate forms complexes with divalent cations. The drug is also incompatible with lipid-based parenteral nutrition solutions (e.g., soybean oil emulsions). It should only be diluted with 0.9% sodium chloride or 5% glucose solution.
The effect of pamidronate on bone scintigraphy (bone scans) should also be noted: the drug can alter scan results. Patients scheduled for bone scintigraphy should inform their radiologist that they are receiving bisphosphonate therapy.
Always inform your treating physician and pharmacist about all medications you are currently taking, have recently taken, or plan to take. This includes prescription medicines, over-the-counter products, vitamins, supplements, and herbal remedies.
What Is the Correct Dosage of Pamifos?
Pamifos is always administered under medical supervision as a slow intravenous infusion. The concentrate (3 mg/ml) must be diluted with a calcium-free infusion solution (0.9% sodium chloride or 5% glucose) before use. The concentration of pamidronate in the final infusion solution should not exceed 90 mg/250 ml. Only freshly prepared, clear, and particle-free solutions may be used.
Tumour-Induced Hypercalcaemia
Patients must be adequately rehydrated with 0.9% sodium chloride before and/or during administration. The total dose per treatment cycle depends on the initial serum calcium level:
| Initial Serum Calcium | Recommended Total Dose | Infusion Concentration | Max Infusion Rate |
|---|---|---|---|
| <3.0 mmol/L (<12.0 mg%) | 15–30 mg | 30 mg / 125 ml | 22.5 mg/h |
| 3.0–3.5 mmol/L (12.0–14.0 mg%) | 30–60 mg | 30 mg/125 ml or 60 mg/250 ml | 22.5 mg/h |
| 3.5–4.0 mmol/L (14.0–16.0 mg%) | 60–90 mg | 60 mg/250 ml or 90 mg/500 ml | 22.5 mg/h |
| >4.0 mmol/L (>16.0 mg%) | 90 mg | 90 mg / 500 ml | 22.5 mg/h |
The total dose may be given in a single infusion or divided over 2–4 consecutive days. The maximum dose per cycle is 90 mg. A significant decrease in serum calcium is generally observed within 24–48 hours, with normalisation typically achieved within 3–7 days. If normocalcaemia is not reached, an additional dose may be given. Treatment can be repeated whenever hypercalcaemia recurs, though clinical experience suggests pamidronate may become less effective with repeated cycles.
Bone Metastases and Multiple Myeloma
| Indication | Dose / Schedule | Infusion Solution | Infusion Rate |
|---|---|---|---|
| Breast cancer skeletal metastases | 90 mg every 3–4 weeks | 90 mg / 250 ml over 2 h | 45 mg/h |
| Multiple myeloma | 90 mg every 4 weeks | 90 mg / 500 ml over 4 h | 22.5 mg/h |
For breast cancer skeletal metastases, the 3-weekly schedule may be preferred to align with chemotherapy cycles. Treatment continues until there is evidence of substantial deterioration in the patient’s general condition. During treatment, patients undergo regular blood tests and possibly urine tests to monitor electrolytes, calcium, phosphate, and renal function.
Renal Impairment
Pamifos must not be administered to patients with severe renal impairment (creatinine clearance <30 ml/min), except in cases of life-threatening tumour-induced hypercalcaemia where the potential benefits outweigh the risks. For patients with mild (creatinine clearance 61–90 ml/min) to moderate (creatinine clearance 30–60 ml/min) renal impairment, no dose adjustment is necessary, but the infusion rate should not exceed 90 mg over 4 hours (approximately 20–22 mg/hour).
If renal function deteriorates during treatment — defined as an increase in serum creatinine of 0.5 mg/dl in patients with normal baseline values, or 1.0 mg/dl in patients with abnormal baseline values — the next dose should be withheld until creatinine returns to within 10% of baseline.
Overdose
Because Pamifos is administered in a hospital setting, overdose is unlikely. However, if symptoms of overdose occur, they may include paraesthesia (tingling or numbness), tetany (muscle cramps, particularly in the jaw, arms, or legs), and hypotension (low blood pressure, causing dizziness). Treatment involves intravenous calcium infusion to counteract these symptoms. Patients who have received higher than recommended doses will be closely monitored by their physician.
What Are the Side Effects of Pamifos?
Like all medicines, Pamifos can cause side effects, although not everyone will experience them. Many of the following side effects can also be associated with the underlying cancer or its treatment. The most characteristic reaction is an acute “flu-like” syndrome with fever (1–2°C increase) occurring within 48 hours of the first infusion, usually resolving within 24 hours. This reaction is considerably less likely with subsequent infusions.
Very Common
May affect more than 1 in 10 patients
- Low blood calcium (hypocalcaemia) and low blood phosphate (hypophosphataemia)
- Fever and flu-like symptoms, sometimes with fatigue, chills, exhaustion, and flushing
Common
May affect up to 1 in 10 patients
- Anaemia (low red blood cells), thrombocytopenia (low platelets), lymphopenia (low lymphocytes)
- Low blood potassium, low blood magnesium
- Symptoms from low calcium: numbness, muscle cramps or spasms
- Headache, insomnia, drowsiness (somnolence)
- Conjunctivitis (red eyes)
- High blood pressure (hypertension)
- Nausea, vomiting, loss of appetite, abdominal pain, diarrhoea, constipation, gastritis
- Skin rash
- Bone, joint, or muscle pain
- Pain, rash, and swelling at the infusion site; inflammation or blood clot in the arm vein; general body pain
- Elevated serum creatinine levels
Uncommon
May affect up to 1 in 100 patients
- Hypersensitivity: wheezing (bronchospasm), difficulty breathing (dyspnoea), swelling of eyelids, lips, and tongue (angioneurotic oedema)
- Seizures, restlessness (agitation), dizziness, lethargy
- Uveitis (inflammation of the uvea in the eye)
- Low blood pressure (hypotension)
- Indigestion, itching, muscle cramps
- Osteonecrosis (bone tissue death)
- Decreased urine output (renal failure)
- Abnormal liver and kidney function tests
Rare
May affect up to 1 in 1,000 patients
- Atypical femoral fractures, particularly in patients on long-term treatment for osteoporosis
- Glomerulosclerosis (a kidney condition with fluid retention, nausea, and fatigue)
- Nephrotic syndrome (protein in urine with swelling of legs and abdomen)
Very Rare
May affect up to 1 in 10,000 patients
- Reactivation of herpes simplex or herpes zoster (shingles)
- Leukopenia (low white blood cell count)
- Anaphylactic shock (life-threatening allergic reaction)
- Elevated blood potassium, elevated blood sodium (hypernatraemia)
- Confusion, disorientation, visual hallucinations
- Episcleritis, scleritis (eye inflammation causing pain and redness)
- Xanthopsia (yellow-tinted vision)
- Worsening heart failure with breathing difficulties
- Acute respiratory distress syndrome (ARDS), interstitial lung disease
- Worsening of pre-existing kidney disease, haematuria (blood in urine), nephritis (kidney inflammation)
Contact your doctor or seek emergency care immediately if you develop: sudden skin rash with itching; swelling of hands, feet, ankles, face, lips, mouth, or throat; difficulty swallowing or breathing (signs of a severe allergic reaction); or symptoms of osteonecrosis of the jaw including persistent jaw pain, non-healing sores in the mouth, numbness, or loose teeth.
Irregular heartbeat (atrial fibrillation) has been observed in patients treated with pamidronate, though it is currently unclear whether pamidronate causes this directly. Patients should report any sensation of irregular heartbeat to their doctor.
Contact your physician if you experience pain, weakness, or discomfort in the thigh, hip, or groin, as this may be an early sign of an atypical femoral fracture. Additionally, if you have ear pain, discharge from the ear, or an ear infection during treatment, report these symptoms as they could indicate bone damage in the ear.
How Should Pamifos Be Stored?
Pamifos should be kept out of the sight and reach of children. Do not use the medicine after the expiry date printed on the vial label and carton after “EXP”. The concentrated solution in its original unopened vial requires no special storage conditions and has a shelf life of 4 years from the date of manufacture.
After dilution with 5% glucose solution or 0.9% sodium chloride solution, the chemical and physical stability of the diluted solution has been demonstrated for 96 hours at 25°C. However, from a microbiological perspective, the diluted solution should be used immediately after preparation. If not used immediately, the maximum storage time should not exceed 24 hours at 2–8°C, unless dilution was performed under controlled and validated aseptic conditions.
Only freshly prepared, clear, and particle-free solutions should be used for infusion. Any remaining solution after use should be discarded. Pamifos concentrate for solution for infusion is intended for single use only.
What Does Pamifos Contain?
Active Ingredient
The active substance is disodium pamidronate, which belongs to the bisphosphonate group. Each millilitre of concentrate contains 3 mg of disodium pamidronate, equivalent to 2.527 mg of pamidronic acid.
Excipients
The other ingredients are sodium hydroxide (for pH adjustment), hydrochloric acid (for pH adjustment), and water for injections. The product contains less than 1 mmol (23 mg) sodium per vial and is therefore essentially sodium-free.
Available Pack Sizes
Pamifos is supplied in glass vials in the following sizes:
- 5 ml vial — contains 15 mg disodium pamidronate (packs of 1, 4, or 10 vials)
- 10 ml vial — contains 30 mg disodium pamidronate (packs of 1, 4, or 10 vials)
- 20 ml vial — contains 60 mg disodium pamidronate (packs of 1, 4, or 10 vials)
- 30 ml vial — contains 90 mg disodium pamidronate (packs of 1, 4, or 10 vials)
Multi-packs containing 4 individual cartons each with 1 vial are also available. Not all pack sizes may be marketed in every country.
Marketing Authorisation Holder and Manufacturer
Pamifos is manufactured by medac Gesellschaft für klinische Spezialpräparate mbH, Theaterstr. 6, 22880 Wedel, Germany. The product is authorised across the European Economic Area and the United Kingdom (Northern Ireland) under the names Pamifos (Denmark, Finland, Slovakia, Sweden, Germany), Medac Disodium Pamidronate (UK/Northern Ireland), Pamipro (Netherlands), and Pamidronate medac (Czech Republic).
Frequently Asked Questions About Pamifos
Pamifos (disodium pamidronate) is a bisphosphonate used for three main indications: treating dangerously high calcium levels in the blood caused by cancer (tumour-induced hypercalcaemia), reducing bone destruction in breast cancer patients whose cancer has spread to the skeleton, and managing osteolytic bone lesions in advanced multiple myeloma. It works by inhibiting the cells that break down bone (osteoclasts), thereby reducing calcium release into the bloodstream and protecting skeletal integrity.
Pamifos is given exclusively as a slow intravenous infusion (drip) in a hospital or clinic setting. The concentrated solution must first be diluted with calcium-free saline or glucose solution. The infusion typically takes 2–4 hours depending on the dose and indication. The maximum infusion rate is 60 mg/hour. It is never given as a rapid injection or taken orally. Treatment frequency ranges from a single infusion for acute hypercalcaemia to regular infusions every 3–4 weeks for bone metastases or myeloma.
The main risks include osteonecrosis of the jaw (bone death in the jaw, especially after dental procedures), kidney damage (requiring monitoring of renal function before each dose), low blood calcium which may cause numbness or muscle cramps, and severe allergic reactions. Atypical femoral fractures have been reported rarely in patients on long-term bisphosphonate therapy. Most patients tolerate Pamifos well, with the most common experience being flu-like symptoms after the first infusion.
Yes, pamidronate can affect kidney function, which is why serum creatinine must be checked before each dose. The risk is reduced by adhering to the recommended infusion rate (never exceeding 60 mg/hour) and ensuring adequate hydration. Patients with pre-existing moderate renal impairment can still receive Pamifos but at a slower infusion rate. Treatment should be paused if creatinine rises significantly, and it should not be given to patients with severe kidney impairment (creatinine clearance below 30 ml/min) except in emergencies.
Yes, a dental examination is recommended before starting Pamifos treatment due to the risk of osteonecrosis of the jaw (ONJ). During treatment, you should maintain good oral hygiene including regular brushing, attend routine dental check-ups, and avoid invasive dental procedures such as tooth extractions. If dental surgery is unavoidable, inform both your oncologist and dentist. Report any jaw pain, mouth sores that do not heal, loose teeth, or numbness in the jaw immediately.
The duration of treatment depends on the indication. For tumour-induced hypercalcaemia, treatment may involve a single infusion or a series over a few days, repeated as needed when calcium levels rise again. For bone metastases from breast cancer and multiple myeloma, infusions are typically given every 3–4 weeks and continued as long as the patient is benefiting and their general condition remains adequate. Your oncologist will determine the optimal treatment duration based on your individual response and overall health.
References
- European Medicines Agency (EMA). Pamidronate disodium — Summary of Product Characteristics. Available at: www.ema.europa.eu.
- British National Formulary (BNF). Pamidronate disodium. National Institute for Health and Care Excellence (NICE), 2025.
- Berenson JR, et al. Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma. New England Journal of Medicine. 1996;334(8):488–493. doi:10.1056/NEJM199602223340802.
- Hortobagyi GN, et al. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. New England Journal of Medicine. 1996;335(24):1785–1791. doi:10.1056/NEJM199612123352401.
- Ruggiero SL, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw — 2022 update. Journal of Oral and Maxillofacial Surgery. 2022;80(5):920–943.
- World Health Organization (WHO). WHO Model List of Essential Medicines — 23rd List. Geneva: WHO; 2023.
- European Society for Medical Oncology (ESMO). Bone health in cancer: clinical practice guidelines. Annals of Oncology. 2020;31(12):1650–1663.
- Major P, et al. Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis. Journal of Clinical Oncology. 2001;19(2):558–567.
- Khan AA, et al. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. Journal of Bone and Mineral Research. 2015;30(1):3–23.
Medical Editorial Team
This article has been written and reviewed by the iMedic Medical Editorial Team, comprising licensed physicians specialising in oncology, clinical pharmacology, and internal medicine. All content is based on current evidence-based guidelines from the European Medicines Agency (EMA), the British National Formulary (BNF), the World Health Organization (WHO), and peer-reviewed medical literature.
iMedic Medical Editorial Team — Specialists in Oncology and Clinical Pharmacology
iMedic Medical Review Board — Independent expert panel following GRADE evidence framework
Evidence standard: Level 1A — Based on systematic reviews and meta-analyses of randomised controlled trials. All medical claims adhere to the GRADE evidence framework and international clinical guidelines.
Conflict of interest: The iMedic Medical Editorial Team has no financial ties to pharmaceutical companies. This content is entirely independent and receives no commercial funding.