Published online: 2020-01-06

Original Article 93

Hypocalcemia following Neridronate Administration in

Pediatric Patients with Osteogenesis Imperfecta:
A Prospective Observational Study
Evelina Maines1 Elisa Tadiotto2 Grazia Morandi3 Michela Fedrizzi4 Rossella Gaudino2
Paolo Cavarzere2 Alessandra Guzzo5 Franco Antoniazzi6

1 Pediatric Unit, Department of Women’s and Children’s Health, Address for correspondence Evelina Maines, MD, Pediatric Unit,
Provincial Centre for Rare Diseases, Azienda Provinciale per i Servizi “S. Chiara” Hospital, Largo Medaglie d’oro, 9, 38122 Trento, Italy
Sanitari della Provincia Autonoma di Trento, Trento, Italy (e-mail: evelina.maines@apss.tn.it).
2 Pediatric Division, Department of Surgical Sciences, Dentistry,

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Gynecology and Pediatrics, University of Verona, Verona, Italy
3 Neonatal Intensive Care Unit, Department of Pediatrics, “C. Poma”
Hospital, Mantova, Italy
4 Pediatric Unit, Pediatric Cardiology Service, Department of
Women’s and Children’s Health, Azienda Provinciale per i Servizi
Sanitari della Provincia Autonoma di Trento, Trento, Italy
5 Laboratory Unit, Department of Neurosciences, Biomedicine and
Movement Sciences, University of Verona, Verona, Italy
6 Department of Surgical Sciences, Dentistry, Gynecology and
Pediatrics, Regional Center for the Diagnosis and Treatment of
Children and Adolescents with Rare Skeletal Disorders, Pediatric
Clinic, University of Verona, Verona, Italy

J Pediatr Genet 2020;9:93–100.

Abstract The use of intravenous bisphosphonates has been linked to hypocalcemia both in
children and adults with osteogenesis imperfecta (OI). The aims of this study were: (1)
to investigate the incidence of hypocalcemia in the first 48 hours (T48) after neridr-
onate infusion in a pediatric population with OI and (2) to assess any correlation
between the baseline values of calcium, vitamin D (25-hydroxyvitamin D) and bone
turnover markers, and the postinfusion calcium values. We conducted a prospective
observational study on 37 pediatric patients. All patients were treated with a single
infusion of neridronate at a dose of 1 to 2 mg/kg. The study provided two postinfusion
reassessments: 24 hours (T24) and T48 after neridronate administration. Hypocalcemia
Keywords was observed in 11% of patients at T24 and in 50% of patients at T48 from neridronate
► neridronate infusion. We observed a positive linear correlation between the baseline vitamin D
► hypocalcemia values and postinfusion calcium values, both at baseline and at T24 and T48.
► osteogenesis Hypocalcemia was mild and asymptomatic in all cases. Postinfusion calcium levels
imperfecta were related to baseline vitamin D levels. Consequently, low vitamin D levels should be
► children considered a significant risk factor for hypocalcemia and should be carefully investi-
► vitamin D deficiency gated and treated before neridronate infusion.

received Copyright © 2020 by Georg Thieme DOI https://doi.org/

September 28, 2019 Verlag KG, Stuttgart · New York 10.1055/s-0039-1700972.
accepted after revision ISSN 2146-4596.
November 25, 2019
published online
January 6, 2020
94 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI
Introduction
Osteogenesis imperfecta (OI) is the most common inherited
bone disorder with an estimated prevalence ranging be-
tween 1 per 10,000 and 1 per 20,000 births.1
OI is mainly characterized by skeletal fragility, low bone
mass, bone deformities, and short stature. The clinical fea-
tures represent a continuum ranging from perinatal death
due to deformities, fractures and respiratory failure to nearly
asymptomatic individuals with a mild predisposition to
fractures, and normal life expectancy.1–3
In ~85 to 90% of cases, the disease is inherited in an
autosomal dominant manner and caused by genetic patho-
genic variants that affect the quantitative (milder forms,
gene COL1A1) or qualitative (moderate to lethal forms, genes
COL1A1 and COL1A2) synthesis of the structural protein type
I collagen.3 The remaining cases are caused by recessive,
dominant, and X-linked mutations in a wide variety of genes
encoding the proteins involved in type I collagen synthesis,
processing, secretion, and posttranslational modification, as
well as in the proteins that regulate the differentiation and
activity of bone-forming cells.4,5 An involvement of the
cytokines Dickkopf-1 and receptor activator of nuclear fac-
tor-κB ligand in the altered bone cell activity associated with
this disease has also been recently demonstrated.6
Despite recent advances in the knowledge of its molecular
basis, OI remains a clinical diagnosis and most recent classi-
fications align with the original classification by Sillence et al.7,8
The approach of managing such a variable disease should
be global and therefore multidisciplinary. The main goals of
OI management are to decrease fracture incidence, relieve
bone pain, promote mobility and growth, and definitely
improve sense of well-being and quality of life.9–12
Bisphosphonate (BP) therapy is currently the most widely
investigated and used treatment for OI.3,13 Many different
compounds, dosage, and protocols have been proposed for OI
patients. By now, the majority of data on OI patients are on
the use of intravenous (IV) pamidronate with increasing data
on zoledronate.
In Italy, neridronate is the only BP registered for OI
treatment. Similar to other BPs, it acts by preventing osteo-
clastic resorption by inhibiting the human farnesyl pyro-
phosphate synthase pathway.14
Although BPs are generally considered safe, some side
effects are reported, including hypocalcemia.15 It is due to a
reduction of the calcium release from the skeleton as a
consequence of the suppression of bone resorption mediated
by osteoclasts.16 Its incidence and severity seem to be related
to the dose and relative potency of the drug.17 Moreover,
hypocalcemia in BP-treated patients appears more frequent-
ly during the first infusions,12 and in patients also affected by
malnutrition or renal failure.17
The use of IV BPs has been linked to hypocalcemia both in
children and adults,17–20 but only few studies have been
conducted in patients with OI.21–29
In the literature, there is only one study reporting the risk
of hypocalcemia in OI patients treated with neridronate.
Gatti et al assessed serum calcium levels 3 to 7 days after
Journal of Pediatric Genetics Vol. 9 No. 2/2020
Maines et al.
the neridronate infusion, observing calcium values ranging
from 8.1 to 9.2 mg/dL (normal range, 8.5–10.2 mg/dL).26
There are no studies assessing the calcium values in the
first 48 hours (T48) following neridronate administration.
Subjects and Methods
Study Population and Study Design
We conducted a prospective observational study on 37
pediatric patients who received IV neridronate for OI at
the Pediatric Clinic of the University of Verona.
Eligibility criteria included patients with a definite diag-
nosis of OI aged between 2 and 20 years. Indications for
treatment were either severe forms of OI with fractures and
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skeletal deformities, or milder forms with pain or vertebral
compressions.
Exclusion criteria were as follows: age > 20 years, history of
hypersensitivity to neridronate or to other BPs, previous treat-
ments with BPs other than neridronate, concomitant acute or
chronic diseases (in particular, parathyroid glands disorders,
rickets, other bone diseases, renal insufficiency, long QT
syndrome), concomitant pharmacological treatments that
may induce hypocalcemia (e.g., antiepileptic drugs, diuretics,
aminoglycosides, proton pump inhibitors, glucocorticoids),30
sustained fractures, or orthopaedic surgical procedures in the
previous 3 months, pregnancy, or breastfeeding.
An interview and an evaluation of the medical history of
each patient were completed to verify the eligibility and
exclusion criteria.
Preinfusion total calcium, ionized calcium, sodium (Na),
potassium (K), chloride (Cl), magnesium (Mg), phosphate
(PO4), albumin, creatinine, parathyroid hormone (PTH), 25-
hydroxyvitamin D (25-OH-D), osteocalcin (OC), carboxy-
terminal cross-linked telopeptide of type 1 collagen (CTX),
total alkaline phosphatase (ALP), and bone alkaline phospha-
tase (bALP) were checked for all patients.
Afterward all patients were treated with a single IV
infusion of neridronate at a dose of 1 to 2 mg/kg (up to a
maximum of 100 mg) in saline solution (0.9% NaCl) (~10 mg/
100 mL), with an infusion time of ~3 hours.
The study provided two postinfusion reassessments:
24 hours (T24) and T48 after the neridronate infusion. The
revaluation included a general examination and a check of
total calcium, ionized calcium, Na, K, Cl, Mg, PO4, albumin,
creatinine, and PTH.
At baseline and at T24, a 12-lead electrocardiographic
recording was performed to evaluate corrected QT (QTc)
interval.
All patients were chronically and systematically treated
with oral calcium carbonate (500–1,000 mg/d), and with oral
vitamin D supplementation to achieve plasma 25-OH-D
levels
75 nmol/L (
30 ng/mL).31
Objectives
Primary End Point
The primary end point of the study was to evaluate the
proportion of children and adolescents affected by OI that
 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI
developed hypocalcemia (asymptomatic or symptomatic) at
a distance of T24 or T48 from the IV neridronate
administration.
Secondary End Points
The secondary objectives of the study were as follows:
• To assess any correlation between the baseline values of
calcium, 25-OH-D and bone turnover markers (ALP, bALP,
OC, and CTX), and postinfusion calcium values to identify
patients at a greater risk of hypocalcemia before the
administration of the drug.
• To assess the proportion of children and adolescents
affected by OI that develops QTc prolongation after ner-
idronate IV administration.
Biochemical Assessments
All blood samples were collected between 9 and 12 am by the
use of a vacuum system after an overnight fast. All determi-
nations were performed in our laboratory. Total and ionized
calcium, Na, K, Cl, Mg, PO4, albumin, ALP, PTH, 25-OH-D, and
creatinine were determined by standardized and certified
procedures.
Serum bALP was determined by a chemiluminescence
immunoassay on a LIAISON analyzer by a commercial meth-
od (DiaSorin LIAISON BAP OSTASE assay, DiaSorin Inc, Still-
water, Minnesota, United States). Intra- and interassay
coefficient of variations (CVs) were maximum 6.1 and 4%,
respectively.
Serum OC was determined by a chemiluminescence im-
munoassay on a LIAISON analyzer by a commercial method
(DiaSorin LIAISON Osteocalcin assay, DiaSorin Inc). Intra-
and interassay CVs were maximum 5 and 6%, respectively.
Serum CTX was determined using the IDS-iSYS automated
immunoassay (Immunodiagnostic Systems, Boldon, UK).
Intra- and inter-assay CVs were maximum 8.8 and 4.9%,
respectively.
Hypocalcemia was considered as total calcium lower than
2.2 mmol/L or as ionized calcium lower than 1.12 mmol/L.32
The following formula was used to “correct” the total calcium
concentration in the setting of hypoalbuminemia (<41 g/L):
Cac ¼ Cam þ (0.8  [decrease in albumin concentration below
normal level in g/L]), where Cac is the total calcium corrected
and Cam is the total calcium measured.32
As bone markers are relatively stable in prepubertal chil-
dren and increase at the beginning of the pubertal growth
spurt,33–35 we analyzed bone turnover markers separately for
prepubertal (n ¼ 14) and pubertal patients (n ¼ 23). Neverthe-
less, since there were no statistical differences between the
two groups, correlations were analyzed without reference to
the pubertal stage.
QTc Evaluation
The electrocardiographic recording was performed for
~10 seconds with a semiautomatic electrocardiograph and
pediatric electrodes. The QTc (where the QT interval is a
measure between the Q and T waves in the electrical cycle of
the heart) was measured in triplicate on the electrocardio-
gram (ECG) at the D2 derivation and was calculated using the
Maines et al. 95
Bazett’s formula (QTc ¼ QT/RR1/2).36 The mean of three
measurements was considered.
QTc was considered prolonged if > 460 milliseconds in
patients <15 years of age, > 470 milliseconds in females
15
years of age, and > 450 milliseconds in males
15 years of
age.37
Since numerous risk factors for QTc interval prolongation
have been described,38–41 we accurately reviewed any con-
comitant pharmacological treatment associated with QTc
prolongation.
Statistical Analysis
Demographic features were summarized by means of de-
scriptive statistics.
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Normally, distributed data were expressed as mean 
standard deviation, minimum and maximum for continuous
variables, and frequency distributions (number and percen-
tages) for categorical variables.
The relationship between the baseline values of calcium,
vitamin D and bone turnover markers, and the value of
postinfusion calcium values was explored using Pearson’s
or Spearman’s correlation coefficient.
The comparisons between the two reassessment groups
(T24 and T48) were performed using Student’s test.
The relationship between the baseline QTc interval and
postinfusion QTc was explored using Pearson’s correlation
coefficient. Since the distribution of calcium values and QTc
was normal, comparisons were performed through Student’s
test.
All statistical analysis was performed using SPSS 14.0
software for Windows (SPSS Inc, Chicago, Illinois, United States).
A p-value of < 0.05 was considered statistically significant.
Ethical Aspects
The latest revision of the Helsinki declaration as well as the
Oviedo declaration was the basis for the ethical conduct of
the study. The study protocol was designed and conducted to
ensure adherence to the principles and procedures of good
clinical practice and to comply with the Italian laws.
The study was approved by the ethics committee for
clinical trials of the Provinces of Verona and Rovigo (72-
CESC/HBPOI). All patients and/or their parents signed an
informed consent.
Results
Baseline
We enrolled 37 children and adolescents affected by OI
(range: 2–19.62 years); of these 20 were males and 17
were females. Twenty-eight patients (76%) were affected
by OI type 1, 5 (13.5%) were affected by OI type 4, and 4
(10.5%) were affected by OI type 3.
The mean serum total calcium was 2.40  0.09 mmol/L
and the mean ionized calcium was 1.22  0.04 mmol/L. Total
calcium values were corrected for albumin (albumin value:
38.1 g/L) in one patient.
One patient presented mild and asymptomatic hypocal-
cemia at baseline (total calcium: 2.19 mmol/L, ionized
Journal of Pediatric Genetics Vol. 9 No. 2/2020
96 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI
calcium: 1.09 mmol/L). The same patient had also vitamin D
insufficiency (64.8 nmol/L). The mean value of 25-OH-D was
85.26  25.58 nmol/L.
Although all patients had been advised to take oral vita-
min D, only 21 patients (57%) had vitamin D sufficiency, 14
patients (38%) had insufficient vitamin D values, and 2
patients (5%) had vitamin D deficiency. We used the follow-
ing cutoff of 25-OH-D to define vitamin D status: vitamin D
deficiency < 50 nmol/L (< 20 ng/mL); vitamin D insufficiency
50 to 74 nmol/L (20–29 ng/mL); vitamin D sufficiency
75
nmol/L (
30 ng/mL), according to the Italian Pediatric
Society and the Italian Society of Preventive and Social
Pediatrics,31 the Endocrine Society,42 and the Society for
Adolescent Health and Medicine.43
At baseline, we observed a linear positive correlation
between the 25-OH-D values and total calcium values
(r ¼ 0.38) (►Fig. 1).
Mean baseline values of ALP, bALP, OC, and CTX were
199  88.95 U/L, 67.97  41.82 μg/L, 9.36  4.73 nmol/L, and
0.779  0.334 ng/mL, respectively.
Twenty-seven patients were enrolled in the T24 group
and 10 patients in the T48 group. With the exception of the
sampling number, the two groups were homogeneous for
age, sex, and biochemical characteristics. In particular, there
were no significant differences in the baseline values of total
and ionized calcium, 25-OH-D and bone turnover markers
(►Table 1).
None of the 27 patients enrolled in the T24 group had
baseline subclinical long QT syndrome nor used drugs asso-
ciated with an increased risk for QTc interval prolongation.
Mean baseline QTc values were 396.7  23.1 milliseconds
(range: 356–428 milliseconds).
T24 Assessments
Twenty-seven patients were re-evaluated after T24 from
neridronate infusion (►Table 2).
Total calcium decreased in 59.2% of patients after neridr-
onate infusions and fell below the normal range only in three
cases (11%). Hypocalcemia was in all cases mild and asymp-
tomatic. It was managed with oral calcium carbonate sup-
plementation (500–1,000 mg daily). No patient presented
ionized calcium value below the normal range.
There was no statistically significant difference (p ¼ 0.65)
between mean calcium values of patients treated with 1
Fig. 1 Positive correlation between 25-OH-D and total calcium values
at baseline. 25-OH-D, 25-hydroxyvitamin D.
Journal of Pediatric Genetics Vol. 9 No. 2/2020
Maines et al.
mg/kg (2.37  0.12 mmol/L) and mean calcium values of
patients treated with 2 mg/kg (2.39  0.10 mmol/L).
We observed a positive linear correlation between the
baseline 25-OH-D values and total calcium values at T24
(r ¼ 0.42), as well as between the baseline total calcium
values and total calcium values at T24 (r ¼ 0.70) (►Fig. 2).
At T24, no correlations between calcium, bone turnover
markers, and PTH values were observed.
At T24, none of the 27 patients had pathological elonga-
tion of the QTc interval (range: 343–440 milliseconds).
Postinfusion QTc value did not differ significantly from
preinfusion QTc value (p ¼ 0.25). The longest measured QTc
was 440 milliseconds in a prepubertal female.
Overall, neither the variation in calcium levels nor the
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dose neridronate correlated with QTc lengthening. Rather,
the baseline QTc interval value correlated significantly with
the postinfusion QTc interval (r ¼ 0.59) (►Fig. 3).
T48 Assessments
Ten patients were re-evaluated after T48 from neridronate
infusion.
Total calcium values decreased from baseline in 60% of
the patients, but no patient presented total calcium value
below the normal range. Five patients (50%) had ionized
calcium values lower than 1.12 mmol/L. Hypocalcemia
was in all cases mild and asymptomatic. It was managed
with calcium carbonate supplementation (500–1,000 mg
daily).
There was no statistically significant difference (p ¼ 0.24)
between mean total calcium value of patients treated with
1 mg/kg (2.42  0.15 mmol/L) and mean total calcium value
of patients treated with 2 mg/kg (2.31  0.04 mmol/L).
At T48, a positive correlation was observed between the
baseline values of 25-OH-D and total calcium values
(r ¼ 0.12) and ionized calcium values (r ¼ 0.38). On the
contrary, no correlation emerged between the baseline
calcium values and the calcium values at T48.
A negative correlation was observed between the baseline
CTX, OC, and ALP values, and the total calcium values at T48
(r: 0.59, 0.46, and 0.20, respectively). Moreover, a posi-
tive correlation resulted between the same baseline bone
turnover markers and postinfusion PTH values (r: 0.64, 0.73,
and 0.39, respectively).
Discussion
This is the first study reporting the occurrence of hypocalce-
mia in the first T48 after IV neridronate administration in
children and adolescents with OI.
Hypocalcemia was observed in 11% of patients after T24
and in 50% of patients after T48 from neridronate infusion.
Hypocalcemia was mild and asymptomatic in all cases.
The incidence of hypocalcemia observed in our study is
slightly higher than the one reported in other studies con-
ducted in children or adolescents with OI using BPs with a
relative potency similar to neridronate.
Other authors have not considered ionized calcium values
as well in their results.
 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI Maines et al. 97

Table 1 Baseline features of our patients

All patients (n ¼ 37) T24 group (n ¼ 27) T48 group (n ¼ 10)

OI type (I/III/IV) 28/5/4 19/4/4 9/1/0
Sex (male/female) 20/17 14/13 6/4
Age (mean  SD) 11.62  4.56 y 11.10  4.59 y 13.04  4.36 y
M: 12.05  4.81
F: 11.12  4.31
Age (range) 2–19.62 y 2–18.6 y 5.8–19.6 y
M: 5.81–19.62
F: 2–18.20
Prepubertal/pubertal 14/23 12/15 2/8
Dose of neridronate 1 mg/kg/ 21/16 15/12 6/4
2 mg/kg

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Total calcium (mmol/L) 2.40  0.09 2.41  0.09 2.39  0.41
(range 2.19–2.56) (range 2.19–2.56) (range 2.22–2.56)
Ionized calcium (mmol/L) 1.22  0.04 1.21  0.04 1.23  0.03
(range 1.09–1.28) (range 1.09–1.28) (range 1.17–1.27)
25-OH-D (nmol/L) 85.26  25.58 85.88  24.93 83.61  28.63
(range: 24.96–154.75) (range: 44.93–154.75) (range: 24.96–117.30)
PTH (pg/mL) 18.31  7.95 18.04  8.35 18.99  7.14
(range: 6–38.70) (range: 6–38.70) (range: 6.90–32.70)
Mg (mmol/L) 0.86  0.05 0.86  0.06 0.86  0.02
(range: 0.77–0.95) (range: 0.77–0.95) (range: 0.84–0.89)
PO4 (mmol/L) 1.31  0.16 1.32  0.14 1.29  0.22
(range: 0.90–1.61) (range: 1.04–1.61) (range: 0.90–1.57)
Creatinine (µmol/L) 42.96  14.70 40.81  13.76 48.37  16.43
(range: 16.80–73.39) (range: 16.80–69.85) (range: 22.99–73.39)
ALP (U/L) 199  88.95 204.2  84.82 185.50  102.50
(range: 51–347) (range: 51–347) (range: 55–338)
bALP (µg/L) 67.97  41.82 72  39.41 64.33  46.16
(range: 11–177) (range: 11–177) (range: 14–140)
OC (µmol/L) 9.36  4.73 9.82  5.08 8.18  3.62
(range: 3.5–19.3) (range: 3.5–19.3) (range: 4.1–15.5)
CTX (µg/mL) 0.779  0.334 0.803  0.331 0.716  0.354
(range: 0.167–1.48) (range: 0.167–1.48) (range: 0.223–1.06)

Abbreviations: ALP, alkaline phosphatase; bALP, bone alkaline phosphatase; CTX, carboxy-terminal cross-linked telopeptide of type 1 collagen; Mg,
magnesium; OC, osteocalcin; OI, osteogenesis imperfecta; 25-OH-D, 25-hydroxyvitamin D; PO4, phosphate; PTH, parathyroid hormone; SD,
standard deviation; T24, 24 hours; T48, 48 hours.

Chilbule and Madhuri 21 performed a retrospective study
on 47 children who received pamidronate for OI or fibrous
dysplasia using three different dosage regimens (A: 1.5
mg/kg/d every 3 months in a single dose; B: 2 mg/kg/d for
3 consecutive days every 6 months; and C: 1 mg/kg/d for 3
consecutive days every 3–4 months). No patient presented
postinfusion hypocalcemia with regimen A, a schedule with
a single infusion like the one used in our study. On the
contrary, postinfusion asymptomatic hypocalcemia was ob-
served in 7.2 and 12% of the patients treated with regimens B
and C, respectively. Two children presented tetany with
severe hypocalcemia on the second or third day with regi-
men B, suggesting that high and repetitive doses may in-
crease the risk. Forin et al22 also observed symptomatic
hypocalcemia in one infant with OI who received pamidro-
nate in cyclic infusions of 3 days.
In the literature, it is reported that the first cycle of BP
treatment is associated with a higher risk of hypocalcemia in
OI patients than the following ones.23–25 All patients of our
study had already been previously treated with neridronate,
so we cannot discuss this point.
We did not observe any correlation between age and
calcium levels. Nevertheless, neonatal age seems to require
special cautions. In fact, Lin et al observed hypocalcemia after
pamidronate infusion in all three OI patients receiving
pamidronate during their first month of life.25
Our study reports a positive correlation between the
baseline vitamin D values and postinfusion calcium values,
remarking the role of vitamin D status in the risk of hypocal-
cemia related to neridronate infusion.
Children and adolescents who had higher baseline vita-
min D values tended to have higher values of calcium both at

Journal of Pediatric Genetics Vol. 9 No. 2/2020

98 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI Maines et al.

Table 2 Biochemical features at T24 and T48 compared with T0

Baseline (mean  SD) T24 (mean  SD) p-Value T48 (mean  SD) p-Value
(n ¼ 37) (n ¼ 27) (Δ T0-T24) (n ¼ 10) (Δ T0-T48)
Total calcium 2.40  0.09 2.38  0.10 0.27 2.38  0.13 0.83
(mmol/L) (range: 2.19–2.57) (range: 2.14–2.61) (range: 2.20–2.60)
Ionized calcium 1.22  0.04 1.21  0.03 0.77 0.98  0.39 0.06
(mmol/L) (range: 1.09–1.28) (range: 1.17–1.25) (range: 0.97–1.25)
PTH (pg/mL) 18.31  7.95 23.57  11.29 0.05 57.82  36.58 0.004
(range: 6.00–38.70) (range: (range:
6.50–43.60) 15.60–38.70)
PO4 (mmol/L) 1.31  0.16 1.32  0.18 0.91 1.37  0.21 0.40
(range: 0.90–1.61) (range: 0.97–1.61) (range: 1.00–1.71)
Mg (mmol/L) 0.86  0.05 0.85  0.08 0.50 0.89  0.08 0.46

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(range: 0.77–0.97) (range: 0.73–1.09) (range: 0.82–1.05)
Creatinine (µmol/L) 42.96  14.70 41.49  14.20 0.82 51.57  18.52 0.68
(range: 16.80–73.39) (range: (range:
19.45–72.50) 22.99–79.93)
Albumin (mg/dL) 46.58  6.39 44.01  2.51 0.10 44.88  3.60 0.22
(range: 38.10–79.80) (range: (range:
36.30–46.60) 39.00–50.20)

Abbreviations: Mg, magnesium; OC, osteocalcin; OI, osteogenesis imperfecta; PO4, phosphate; PTH, parathyroid hormone; SD, standard deviation;
T24, 24 hours; T48, 48 hours.
Note: Bold represents statistically significant values.

baseline and at T24 and T48 as well. Although all patients
were advised to take calcium and vitamin D supplementa-
tion, 38% had insufficient vitamin D values and 5% had
vitamin D deficiency. As a consequence, we can hypothesize
that ~43% of the patients enrolled in the study showed poor
adherence to chronic home therapy, at least to vitamin D
supplementation. These data are in line with the literature,
which shows that on average the level of adherence to long-
term treatments for chronic diseases in developed countries
is only 50%. Specifically, in children and adolescents, the
range of treatment adhesion ranges from 43 to 100%, with an
average of 58% in developed countries.44,45
No patient presented hyperparathyroidism at baseline, but
we observed a significant increase in the PTH value at both T24
and T48. The transient increase in PTH secondary to BPs
administration has to be considered as a counter-regulation
mechanism for the maintenance of normal calcium values, and
it has been previously described in other studies.46–48
Chilbule and Madhuri21 reported a correlation between
the pamidronate dose and the incidence of treatment-relat-
ed complications, in particular, hypocalcemia. Our study did
not observe any statistically significant differences in calci-
um levels in relation to the two different neridronate dos-
ages, neither at T24 nor at T48.
A positive correlation has been observed in our study
between the baseline bone turnover markers and calcium
levels. These data are in line with the literature, where an
increase in calcium levels has been observed in high turnover
bone diseases (e.g., Paget’s disease, hyperthyroidism).46

Fig. 2 Positive correlation between baseline 25-OH-D and total

calcium values, and total calcium values at T24. 25-OH-D, 25- Fig. 3 Positive correlation between baseline QTc and QTc at T24. T24,
hydroxyvitamin D; T24, 24 hours. 24 hours.

Journal of Pediatric Genetics Vol. 9 No. 2/2020

 Hypocalcemia following Neridronate Administration in Pediatric Patients with OI
On the contrary, we observed a negative correlation
between the baseline bone turnover markers and calcium
values at T24 and T48. In accordance with this observation,
patients with higher baseline bone turnover markers have
higher values of PTH.
Several studies have shown that the rate of bone turnover is
the main determinant of the proportion of administered BP
that is retained in the bone tissue. It is known that patients
with high turnover diseases present more severe hypocalce-
mia and secondary hyperparathyroidism and retain more
medication than patients with lower turnover diseases.49
Therefore, it can be hypothesized that hypocalcemia and
hyperparathyroidism secondary to neridronate administra-
tion in OI patients could be more severe in patients with high
bone turnover.
This study has not observed any pathological prolonga-
tion of the QTc interval T24 after the administration of
neridronate. Moreover, the elongation of the QTc interval
was not correlated to the variation of the calcium levels, as
already observed in the literature.20 Instead, the QTc interval
values before drug administration are positively correlated
with the postinfusion QTc interval values.
Since the higher incidence of hypocalcemia was observed
at T48, this study probably underestimated the risk of
prolongation of the QTc interval. Rothenbuhler et al20 ob-
served that 7% of patients with severe osteoporosis attribut-
able to cerebral palsy had prolongation of the QTc interval
T24 after the second infusion of pamidronate (T48 after the
first one).
An evaluation of the QTc interval also after the first T24
from neridronate administration is necessary to establish the
real risk of prolongation of the QTc interval in children and
adolescents treated for OI. Other limitations of the study are
the small sample size of our patient cohort and the different
allocation of the patients across the two study arms.
Conclusion
Hypocalcemia related to neridronate administration was
mild and asymptomatic in all cases. Postinfusion calcium
levels were related to baseline vitamin D levels. Consequent-
ly, low vitamin D levels are to be considered a significant risk
factor for hypocalcemia and should be carefully investigated
and treated before neridronate infusion. Low rates of adher-
ence to chronic vitamin D and calcium prophylaxis should
always be taken into consideration.
Our study also suggests to exclude before the treatment
the presence of concomitant factors that may compromise
the counter-regulatory response to hypocalcemia, in partic-
ular, hypoparathyroidism.
Patients with higher bone turnover markers seem to be
more at risk of hypocalcemia, probably because they could
retain a larger amount of the drug in the skeleton.
Authors’ Contributions
E.M. conceived the work and wrote the draft; E.T. and G.T.
revised the manuscript and prepared figures and tables;
M.F. did ECG interpretation and revised the draft; A.G.
Maines et al. 99
performed laboratory analysis; R.G. and P.C. ensured the
accuracy of the data and revised the manuscript critically
for important intellectual content. The authors acknowl-
edge that they participated sufficiently in the work to take
public responsibility for its content. All the authors ap-
prove the submitted version of the manuscript.
Compliance with Ethical Standards
The latest revision of the Helsinki declaration as well as the
Oviedo declaration was the basis for the ethical conduct of
the study. The study protocol was designed and conducted
to ensure adherence to the principles and procedures of
good clinical practice and to comply with the Italian laws.
The study was approved by the ethics committee for
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
clinical trials of the Provinces of Verona and Rovigo (72-
CESC/HBPOI). All patients and/or their parents signed an
informed consent.
Funding
None.
Conflict of Interest
None declared.
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