6.6.1.2 Bisphosphonates

ChoiceDrugDosage
Formulary choicesRisedronate sodium tablets 35mg

Dose:
35mg once weekly. Take with a full glass of water on an empty stomach at least 30 minutes before breakfast and other medication (e.g. calcium supplements). Stand or sit upright for at least 30 minutes and do not lie down until after breakfast

Or
Alendronic acid tablets 70mgDose:
70mg once weekly. Take with a full glass of water on an empty stomach at least 30 minutes before breakfast and other medication (e.g. calcium supplements). Stand or sit upright for at least 30 minutes and do not lie down until after breakfast

Prescribing Notes

  • See NICE TA464 bisphosphonates for treating osteoporosis.
  • People receiving drug treatment for osteoporosis (unless confident that the patient is receiving an adequate dietary intake) should receive a vitamin D supplement (+/- calcium). Click here for formulary choices.
  • Before starting treatment, calcium, phosphate, alkaline phosphatase and renal function should be checked.
  • Due to concerns about these potential side effects of long-term bisphosphonate therapy patients should be assessed for benefit and on-going need after 5 years of oral bisphosphonate therapy. For those patients who are then deemed at continued high risk of fracture and who continue to receive treatment, local expert opinion is that no patient should receive continuous oral bisphosphonate therapy for more than 10 years without referral to a specialist.
  • GI Side Effects
    • bisphosphonates have complex administration instructions. GI side effects are minimised by following these instructions
    • oral bisphosphonates should be avoided in anyone with a history of oesophageal stricture or severe oesophagitis
    • risedronate may be preferable in those patients that have a history of (recent) proven peptic ulcer disease, active GORD, or develop significant GI side effects on alendronate
    • PPIs are unlikely to be helpful as GI complaints are due to local irritant effect
  • Long term adherence is poor and patients should be encouraged to continue taking their bisphosphonate.
  • Monthly oral ibandronate is an alternative option for younger patients who have predominantly spinal osteoporosis (no data is available for hip fracture).
  • The intravenous bisphosphonates zoledronic acid and ibandronic acid are red list drugs for specialist use only.

Cautions

  • Renal impairment:
    • alendronate should be avoided if eGFR <35mL/min
    • risedronate should be avoided if eGFR < 30mL/min
  • High dose IV bisphosphonate therapy is associated with osteonecrosis of the jaw. It is rarely associated with oral bisphosphonates. History of poor dentition is a risk factor. Refer to MHRA advice.
  • Atypical femoral fracture has been reported rarely with bisphosphonate treatment, mainly in patients receiving long-term treatment for osteoporosis. Patients should be advised to report any thigh, hip or groin pain. The need to continue bisphosphonate treatment for osteoporosis should be re-evaluated periodically based on the benefits and potential risks of bisphosphonate therapy for individual patients, particularly after 5 or more years of use and should not exceed 10 years. See MHRA warning for further details.
  • Osteonecrosis of the external auditory canal has been reported very rarely with bisphosphonates. For full details see MHRA warning.