Introduction

Hypercalcaemia, bone pain and pathological fractures are potentially distressing complications of cancer, and increase the likelihood of unwanted admissions to hospital. Bisphosphonates are one of several possible treatment options.1 Although they can be given orally, intravenous administration is required for malignant hypercalcaemia, or for other indications if swallowing is burdensome.

At the start of the COVID-19 pandemic, when attempts were made to limit risks associated with attending healthcare facilities for procedures, we discussed alternative options with patients who had been receiving intravenous zoledronic acid at our palliative care day centre. However, intravenous cannulation was not always feasible in the home setting. Therefore, we discussed switching to either subcutaneous denosumab or subcutaneous pamidronate2 as alternatives. The subcutaneous administration of clodronate is also reported,3 but clodronate is not available in the UK.

However, a patient who had previously responded well to intravenous zoledronic acid asked whether this too could be administered subcutaneously. Having found no reports of extravasation reactions and discussed the uncertainties and possible risks, we proceeded, and it was well tolerated. This led to cautious discussions with other patients wishing to remain at home or with inpatients with fragile veins or expressing a clear preference to avoid cannulation due to pain. Because it appeared …