Bisphosphonates

Last updated:February 18, 2024

Bisphosphonates can be taken by both men and women to treat osteoporosis.

They are often prescribed during cancer treatments because many chemo combinations can tax bone structure and cause osteoporosis.

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Common Names

Fosamax (alendronate), Actonel (risedronate), Boniva (Ibandronate), Reclast (zoledronic acid)

Side Effects and What to Do About Them

The biggest issues with oral bisphosphonates (Actonel, Boniva, Fosamax) are nausea, abdominal pain and heartburn. To alleviate these side effects, take the medication with a full glass of water (milk is not recommended) on an empty stomach and remain upright for 30 to 60 minutes to avoid the medicine coming back up into the esophagus. Once the recommended wait time is over, eat to offset the remaining medication. There are other medicines that can be taken to ease digestive discomfort, or you doctor might suggest lowering the dose.

Low calcium in the blood (hypocalcemia) can cause muscle twitching, spasms and cramps, numbness or tingling in feet hands and around the mouth. Don’t ignore these symptoms. If low calcium in the blood is untreated it could lead to depression, dry skin, itching and (rarely) fits.

Increased bone pain can happen for a short time when you start on bisphosphonates. Your doctor will probably suggest Tylenol (acetaminophen) to deal with the pain.

Bisphosphonates given intravenously, such as Reclast, are taken by patients who find it easier to schedule a quarterly or yearly infusion instead of taking a weekly or monthly pill. Infused forms of bisphosphonates can cause 24 to 72 hours of mild flu-like symptoms.

The possible long-term effects of bisphosphonates include atypical femur fracture, osteonecrosis of the jaw (ONJ), atrial fibrillation, damage to the kidneys and esophageal cancer.

Atypical femur (thigh bone) fractures are rare, but these fractures can happen in the hip or the neck of the femur. According to E. Michael Lewiecki, MD, director of the New Mexico Clinical Research & Osteoporosis Center, and clinical assistant professor of medicine, University of New Mexico School of Medicine, these fractures usually occur in patients who have taken bisphosphonates for 7 years or more.

According to Harvard Medical School, there have been some unusual fractures of the femur in long-term Fosamax users. However, there is no concrete evidence yet to make any conclusions. Consequently, doctors do not know how long patients should take Fosamax. Some women and their physicians consider a drug holiday if using bisphosphonates.

ONJ is a condition in which bone in the jaw that becomes exposed and begins to weaken from a lack of blood. Luckily, oral bisphosphonate users rarely experience ONJ. Current estimates are that between 1 in 10,000 and 1 in 100,000 patients who have taken bisphosphonates have had ONJ. But the research shows the risk of ONJ in patients with cancer treated with high doses of intravenous bisphosphonates is higher, in the range of 1-10 per 100 patients (depending on the duration of therapy).

Always tell your dentist that you are having bisphosphonate therapy or tell your doctor if you need dental treatment.

Atrial fibrillation is a common type of heart rate problem that might be linked to IV bisphosphonates.

Pooled data from randomized controlled trials and observational studies show that there is a higher risk of atrial fibrillation from bisphosphonates, according to the National Center for Biotechnology Information. (Randomized controlled trials are considered very high quality. However, pooling studies means combining findings from studies with different parameters, people tested and goals of the studies. So that makes it a bit less reliable, but still good.)

Your doctor might want to check your kidney functioning before starting bisphosphonates and occasionally after starting. Drinking plenty of fluids can help protect your kidneys. You should alert your doctor if your urine output drops. Kidney damage is rare but possible.

Additionally, there are some concerns about bisphosphonate treatment and esophageal cancer. However, the National Institutes of Health examined several studies and doesn’t see any correlation.

Drug Interactions

Combining oral bisphosphonates and calcium or acid-suppressant medications can interfere with the absorption of the bisphosphonate. Therefore, calcium supplementation should not be taken while using bisphosphonates. There is also a risk of fracture.

It’s also recommended to be cautious with oral bisphosphonates and over-the-counter pain meds (known as NSAIDs: non-steroidal anti-inflammatory drugs) because this combination can irritate the gastric mucosa, a layer of the stomach.

Effectiveness & Considerations

Bisphosphonates are commonly prescribed for osteoporosis treatment and other bone diseases. There are some studies that show differences in potency or effectiveness at preserving bone density, but all bisphosphonates are generally considered helpful. Bisphosphonates have shown to reduce the chance of a fracture.

Experts say patients can take bisphosphonates for 3 to 5 years. There are plenty of studies that prove these drugs are safe and effective at preventing fractures of the hip and spine.

In addition, in order to maximize the benefit of bisphosphonates, people should be sure their intake of calcium and vitamin D is adequate both before and during therapy.

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If an individual has not broken any bones and continues to maintain bone density for 5 years while taking bisphosphonates, then experts believe patients should consider taking a break from their medication because there is little research about the drug’s effectiveness beyond 5 years.

Bisphosphonates are used to lower the chance of fracture but remember, they don’t eliminate all risk of breaking a bone. If a patient experiences a fracture while on treatment, the doctor will assess the situation and see what the next step is.

According to The New York Times, the most commonly prescribed osteoporosis drugs like Fosamax fell by 50% from 2008 to 2012 and the trend is continuing. Millions of Americans choose to avoid these drugs because they are terrified by the extremely rare side effects.

Alternatives to Bisphosphonates

For those who have a higher risk of bone loss, a great way to improve bone health is to provide your body with specific bone-building nutrients like vitamin K and vitamin D. Appropriate doses of vitamin D have been shown to reduce fractures as effectively as drug therapies.

Eating an alkaline-forming diet can offset the acid load that comes from large amounts of animal protein, processed foods, refined sugars, and poor quality salts. This kind of diet replaces all of the unhealthy acid load with more fruits, vegetables, and seeds to build bone. Note that alkalizing your diet is good in the short-term but detrimental in the long run.

Exercising can help prevent bone loss through building muscle and extensive strength training. Taking walks or enrolling in a yoga class are some ways to include exercise in your everyday life to build muscle and bone.

How They Work (Method of Action)

Bones are made of living tissue and constantly change. Healthy bones have specialized bone cells that break down and replace bone tissue. The specialized bone cells are osteoclasts, which break down old bone, and osteoblasts, which build new bone. The job of bisphosphonates is to slow down osteoclasts, allowing less bone loss and osteoclasts to work more effectively.