denosumab + pamidronate + zoledronate

This is a combination of three bone-modifying agents—denosumab, pamidronate, and zoledronate—used to manage conditions involving increased bone resorption such as metastatic bone disease, multiple myeloma, hypercalcemia of malignancy, and severe osteoporosis. Denosumab is a fully human monoclonal antibody that inhibits RANK ligand (RANKL), thereby preventing osteoclast formation and activity. Pamidronate and zoledronate are both bisphosphonates that inhibit farnesyl pyrophosphate synthase in the mevalonate pathway within osteoclasts, leading to reduced bone resorption by disrupting osteoclast function. These agents help prevent skeletal-related events (SREs) such as fractures or hypercalcemia in cancer patients with bone metastases or other high-risk populations[1][2][3][6].