Oral Bisphosphonates

Introduction

Bisphosphonates (antiresorptive medications) are first-line therapy used for prevention and treatment of osteoporosis.

  • Options include alendronate (oral), ibandronic acid (oral or IV), pamidronate (IV), risedronate (oral), zoledronic acid (IV).



Oral Dosage

  • Alendronate: 10 mg daily or 70 mg once a week
  • Ibandronic acid: 150 mg once monthly
  • Risedronate: 5 mg daily or 35 mg once a week or 150 mg once monthly



Method of Administration

Oral bisphosphonates bioavailability is less than 1% and is greatly decreased with concomitant food and beverages.
  • Each oral tablet should be taken in the morning with at least 6 oz (180 ml) of plain water (not coffee, juice, mineral water, or milk) at least 30 minutes (60 minutes for oral ibandronate) before consuming any food, supplements, or medications.
  • An exception is delayed-release risedronate, which is administered immediately after breakfast with at least 4 oz (120 ml) of plain water.



Missed Dose Management

If patient misses a weekly dose, it can be taken the next day. If more than 1 day has elapsed, that dose is skipped until the next scheduled ingestion.

If a patient misses a monthly dose, it can be taken up to 7 days before the next scheduled dose.



Adverse Effects

Upper gastrointestinal (GI) side effects (reflux, oesophagitis, oesophageal ulcers) are a commonly cited reason for oral bisphosphonate intolerance.

  • The patient should remain upright (sitting or standing) for at least 30 minutes after alendronate and risedronate and 1 hour after ibandronate administration to prevent oesophageal irritation and ulceration.

Both oral and IV bisphosphonates can cause transient hypocalcaemia, but it occurs more frequently after IV than oral administration.

  • Ensure vitamin D status and calcium intake are adequate; if necessary, prescribe supplements (to be taken at a different time of day to oral bisphosphonates).

Rare adverse effects include osteonecrosis of the jaw (ONJ), severe musculoskeletal pain, ocular side effects and subtrochanteric femoral (atypical) fractures.

  • There are rare complications with some dental procedures in people taking bisphosphonates; tell your doctor if you require any dental work and tell your dentist that you are taking this medicine (or have taken it in the past).
  • ONJ occurs more commonly in patients with cancer, receiving higher-dose intravenous bisphosphonate therapy and other risk factors including glucocorticoid therapy and diabetes mellitus.
  • Although rare, some patients have experienced severe musculoskeletal pain (bone, joint, and/or muscle pain) within days, months, or years after starting a bisphosphonate, and symptoms do not always resolve completely with discontinuation of therapy.
  • Ocular side effects including pain, blurred vision, conjunctivitis, uveitis, and scleritis have been reported with most bisphosphonates
  • Drug holidays are controversial; bone density may decrease 5 years after discontinuation of bisphosphonate therapy.



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