Bisphosphonates are frequently used in the management of osteoporosis. They are often the go-to agent for this condition. Below we provide a bisphosphonate comparison table and I also wanted to highlight some of the most important clinical pearls that we should teach our patients and colleagues.

Oral administration of bisphosphonates is not something to take lightly. These drugs have strict requirements. Oral bisphosphonates should be administered first thing in the morning and prior to any food or medications. In addition, it should be taken with a full glass of water with the patient remaining upright for 30 minutes. This helps prevent esophagitis. Avoiding coadministration with food and other medications helps aid in maximizing absorption of the drug.

Another challenge with bisphosphonates is the length of use. 5 years is the magic number with oral bisphosphonates. That is the time to reassess if longer-term therapy is warranted or not. This decision is usually based upon the risk for future fracture when looking at the patient’s previous history.

Renal function is important to monitor with the use of bisphosphonates. Zoledronic acid is contraindicated if renal function is below 35 mls/min. Using oral bisphosphonates is controversial in patients with a GFR of less than 30 mls/min. In practice, I’ve seen it done. The challenge is that there isn’t a lot of clinical literature either supporting the safety of use or demonstrating harm if used in patients who have a GFR of less than 30 mls/min.

Bisphosphonate Comparison Table

	Alendronate	Risedronate	Ibandronate	Zoledronic acid	Pamidronate
Brand name	Fosamax, Binosto	Actonel, Atelvia	Boniva	Reclast, Zometa	Aredia
FDA approval	Osteoporosis in males and postmenopausal females. Treatment of glucocorticoid-induced osteoporosis. Paget disease.	Osteoporosis in males and postmenopausal females. Treatment and prevention of glucocorticoid-induced osteoporosis. Paget disease.	Osteoporosis in postmenopausal females.	Osteoporosis in males and postmenopausal females. Bone metastases. Hypercalcemia of malignancy. Paget disease	Hypercalcemia of malignancy. Bone metastases or osteolytic lesions. Paget disease.
CrCl	<35mL/min: use not recommended	<30mL/min: use not recommended	<30mL/min: use not recommended	<35mL/min: use contraindicated	<30mL/min: contraindicated or dose-adjusted depending on disease
Route of administration	Orally	Orally	Orally or IV	IV	IV
Dosage form	Solution, tablet, effervescent tablet	Tablet	Tablet, IV solution	IV solution, IV concentrate	IV solution
Frequency	Weekly or daily	Weekly or daily	Monthly or every 3 months	Yearly or every other year	Depends on disease Minimum: weekly
Osteoporosis prevention dosing	35 mg once a week or 10mg daily	5mg once daily or 35mg once weekly or 150mg once monthly	Oral: 150mg once monthly	5mg once every 2 years	N/A
Osteoporosis treatment dosing	70mg once a week or 10mg daily	35mg once a week or 5mg daily or 150mg once a month	Oral: 150mg once a month IV: 3mg every 3 months	5mg once every 12 months	N/A
Duration of therapy	5-10 years	5-10 years	Oral: 5-10 years IV: 3 years	3-6 years	Not known

What other issues have you seen come up with bisphosphonates?

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