What precautions should be considered before prescribing bisphosphonates

What precautions should be considered before prescribing bisphosphonates?

• Oral bisphosphonates are contraindicated in patients with esophageal problems (strictures, achalasia, or severe dysmotility [scleroderma], varices), malabsorption, or inability to sit upright. These are indications for an IV formulation.

• Oral bisphosphonates are contraindicated in patients with creatinine clearance (CrCl) <30 to 35 cc/minute and IV bisphosphonates are contraindicated if CrCl <35 to 40 cc/minute due to renal excretion. Patients with severe stage 3 chronic kidney disease (CKD; CrCl 35–40 cc/minute) who are receiving IV bisphosphonates should be taken off drugs affecting renal function if possible (nonsteroidal antiinflammatory drugs, diuretics), be well hydrated, and have slower infusion rates (ibandronate 15 minutes; zoledronic acid 60 minutes). IV ibandronate is probably safer than IV zoledronic acid due to less effect on renal tissue.

• All planned invasive dental work should be performed prior to starting a bisphosphonate, if possible, to lessen future risk for ONJ. It is recommended that providers do an oral examination before starting therapy with bisphosphonates.

• Make sure 25OH vitamin D is >20 (preferably 30) ng/mL before starting therapy.

• IV bisphosphonates can cause a flu-like illness and bone pain lasting up to 2 to 3 days in 10% (ibandronate) to 30% (zoledronic acid) of patients. Premedication with acetaminophen will often prevent or lessen these symptoms.

• Compliance is important. Failure to take a bisphosphonate at least 70% of the time significantly decreases its fracture protection.

• BMD increase is less with low turnover and perimenopausal patients.

• Fracture protection has not been proven in osteopenic patients especially aged <65 years. Use FRAX to determine need for therapy.

• Bisphosphonates are contraindicated in patients who are pregnant or breastfeeding due to unknown effects on the developing skeleton. In the rare patient who requires a bisphosphonate and may want to get pregnant in the future, risedronate may be the safest to use due to more rapid clearance from the blood after it is stopped. However, risedronate should be stopped 6 months prior to getting pregnant.

• Unusual side effects from bisphosphonates: ocular symptoms including uveitis, keratitis, optic neuritis, and orbital swelling have been reported. Atrial fibrillation has also been reported. All these are more common with IV preparations.