Tips for Reclast Injection

@JustinMcClanahan
Thank you for this info.

@harborside24
Thank you for posting this. I recall sometime ago that endodoc was quoted in more detail on this topic, but I can’t seem to find the source of it.

Would you happen to have the full text of that earlier post?

@rwdlaw I cannot locate it. So sorry!

I think I can find the post. Can you tell me what you remember of it.

@gently
“ Advice from an anonymous. expert who has treated many patients with IV zoledronic acid and played a key role in the development of Fosamax, oral and IV Boniva
"There are 3 things I routinely do when I treat patients with IV zoledronic that not all physicians understand. First, I order the infusion to dilute the 5 mg of zoledronic acid (which comes in 100 mL of D5W) into 500 mL of NS (normal saline), thereby diluting the drug from 5 mg% to 0.8 mg%. Then I order it to be administrated over 60 minutes, instead of 15 minutes. Giving an N-BP more dilute and more slowly makes it even safety for the kidneys. The 3rd thing I always do is order the infusion nurses to administer 650 mg of acetaminophen to the patient during the infusion, and I tell the patient to take at home the same dose of acetaminophen (two regular strength Tylenols) with dinner and at bedtime the day of the infusion, with all 3 meals and at bedtime the day after the infusion, and a final (7th) dose with breakfast the 2nd morning after the infusion. These 8 doses total of acetaminophen reduce the chance of a symptomatic APR from 20-30% to < 1%.The other thing to consider is that in most patients, a 5 mg infusion of zoledronic acid will control the rate of bone turnover for at least 24 months, so most of my patients do not get annual infusions."

@rwdlaw

I found it!

@rwdlaw

Here is the rest of it

“ When amino-bisphosphonates (N-BPs) are administered IV, resulting in a high systemic exposure (unlike when taken orally, where the very low oral bioavailability results in a quite low systemic exposure), phagocytic cells other than just osteoclasts can encounter the N-BP, Up to 30% of patients can experience an APR (acute phase reaction) after their initial infusion of zoledronic acid. This APR, which starts usually about 6 hours post-infusion, and can last several days, consists of a mild fever associated with muscle and joint pains, similar to the symptoms with a bad viral infection such as the flu. And it turns out that the cause is very similar, as well. When a special category of phagocytic T-cells, called gamma-delta T-cells, encounter the zoledronic acid, they engulf it, just like an osteoclast will engulf alendronate or zoledronic bound to the bone surface. And just like an osteoclast that engulfs a N_BP undergoes apoptosis (programmed cell death), the gamma-delta T-cells that engulfs a N-BP also undergoes apoptosis. The difference is, when a gamma-delta T-cell undergoes apoptosis, it releases inflammatory cytokines, such as IL-1, IL-6, and TNF-alpha, just like when it encounters a flu virus. And these inflammatory cytokines mediate the temperature rise and myalgias, just as with a flu infection."

@gently

I think that may have been your post originally

@gently @harborside24

My endo refused to even consider that protocol, however, my oncologist took time to study it and discuss it with the hospital pharmacist and has agreed to write the order.

Of course now, I have to overcome my fear of the infusion, which seems to be getting worse after reading more about all the horrible side effects as my infusion date draws nearer!

I am also about to start Reclast this summer so I have an interest here!

I can't find any articles that discussion the effect of dilution on APR (acute phase reaction--i.e. side effects) of Reclast infusions. My editorial comment is that perhaps studying the effects of taking another medication (anti-inflammatories) that is cheap and easy is more likely to be funded that studying the effects of a slower infusion that will take additional time and therefore cost more. No evidence about infusion time that I found to present to a provider.

There are a bunch that talk about use of ibuprofen and other anti-inflammatories and they find that pre- and post- infusion anti-inflammatories reduce the incidence of pain but probably not fever. It was discouraging to read in a 2025 study that the incidence of APR after anti-inflammatories was 38.0% vs. 53.2% without. That is, incidence is high no matter what.
https://pubmed.ncbi.nlm.nih.gov/41099084/
Several articles mention that good levels of vitamin D before the infusion reduces side effects, as does calcium (not just pills right before or after, but generally good levels of both). Hydration is also frequently mentioned.

This article says that the use of dexamethosone (a strong anti-inflammatory) for 3 days following the infusion reduced APR. I can't get the article itself, just this abstract. https://pubmed.ncbi.nlm.nih.gov/36970850/