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Neurological Rehabilitation

Session: Slow infusion of intravenous zoledronic acid for prevention and treatment of sub-lesional osteoporosis following spinal cord injury: Safety considerations in outpatient setting

Slow Infusion of Intravenous Zoledronic Acid for Prevention and Treatment of Sub-Lesional Osteoporosis Following Spinal Cord Injury: Safety Considerations in Outpatient Setting

Thursday, October 23, 2025
12:45 PM - 2:15 PM MT
Location: Kiosk 10

    Poster Presenter(s)

  • Simranjeet Benipal, MD

    Resident Physician
    MetroHealth Rehabilitation Institute
    Cleveland, Ohio

    • Co-Author(s)

  • CO

    Christina Victoria Oleson, MD

    Director, Neuro-Osteoporosis Program, MetroHealth Rehabilitation Institute, Cleveland OH
    Case Western Reserve University
    Beachwood, Ohio

Disclosure(s):
Simranjeet Benipal, MD: No financial relationships to disclose
Background and/or Objectives: Individuals with spinal cord injury (SCI) experience increased bone turnover due to initial osteoclastic upregulation and subsequent osteoblastic downregulation with prolonged immobility. An estimated 33% of bone mineral density (BMD) below the injury level is lost by 1-2 years post-SCI. Prior research indicates that intravenous (IV) zoledronic acid (ZA) maintains BMD at the distal femur and total hip for 6-12 months. Due to potential post-infusion adverse fevers, hypocalcemia, and nephrotoxicity, we proposed a slower ZA infusion with additional prophylactic measures.

Design: Development and implementation of pilot protocol

Setting : Outpatient SCI clinic and hospital infusion center

Participants : Three SCI individuals who received pilot protocol

Interventions: Outpatient protocol was adapted from a previously published inpatient protocol. Treatment protocol development evolved from discussion with pharmacy, laboratory, and infusion center team leaders. Essential steps included lab screening; patient education and informed consent; pre-infusion optimization of electrolytes, calcium, and vitamin D; peri-infusion administration of calcium, and ongoing vitamin D prescription. Tylenol was given every 4 hours, starting 4 hours prior to IV ZA and ending 24 hours after ZA completion. Intravenous saline was given before, during, and after a prolonged two-hour delivery of IV ZA. Total time of IV saline and ZA was 5 hours. Post-infusion monitoring of temperature, renal function, and calcium was conducted.

Main Outcome Measures: Successful implementation of protocol steps and creation of an EPIC order set for patient delivery

Results: Protocol was effectively delivered for three patients without deviations. Creation of EPIC order set went live in March 2025. No hypocalcemia or acute kidney injury was observed. One patient had febrile episodes for 24 hours post-infusion.

Conclusions: Slow infusion of zoledronic acid with prophylactic measures to address hypocalcemia, acute phase reactants, and nephrotoxicity is needed in the outpatient setting. The above protocol may provide a safer option than standard 30-minute administration of ZA for individuals with SCI.