Bisphosphonate Therapy

Bisphosphonates are a group of medicines used to treat osteopenia and osteoporosis, which are conditions associated with thin or fragile bones that are at increased risk for fracture. Bisphosphonates work by reducing the turnover of bone which lowers the risk of fracture. Patients with low bone density or a history of fractures may be recommended to take these medications. Disorders such as Paget’s disease or cancer that have spread (metastasized) to the bone are other indications for use. Patients on long-term oral steroid medications may also be recommended to take these medications to prevent developing osteoporosis.

Bisphosphonate medications include alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). Pamidronate, ibandronate, and zoledronic acid (Reclast/Zometa) are options to be administered through your vein (intravenously).

How To Take It

Alendronate, risedronate, and ibandronate are oral medications for osteoporosis treatment. Alendronate is given 70 mg once a week. Risedronate is given 35 mg weekly or 150 mg monthly. Ibandronate is given 150 mg once a month. These medications must be taken first thing in the morning on an empty stomach with an 8 oz glass of water. Do not take it with other beverages. You must remain upright (sitting or standing—no lying down) for 30–60 minutes after taking the medication. Do not take any additional medications, beverages, or food for 30–60 minutes after taking the medication. This improves the absorption of the medication and prevents the most common side effect, which is heart burn or acid reflux. Zoledronic acid is administered at your doctor’s office or at an infusion center. The dose is 5 mg once a year. The duration of treatment varies for each patient but is not likely to be a life-long medication. Most patients will require treatment for osteoporosis for 3–5 years.

Side Effects

Side effects of oral bisphosphonates include muscle cramps/pain, difficulty swallowing, heartburn, abdominal pain, headache, and/or rash. Side effects of zoledronic acid include low blood pressure, dizziness, headaches, muscle pain, nausea, constipation, fever, and/or rash. These side effects may last 1–2 days and up to 10–12 days after your infusion.

There is a rare risk of developing damage to the cells within the bones of the jaw called osteonecrosis.

It is recommended that you have a good dental exam prior to starting these medications. If you are planning to have an invasive procedure, such as a dental implant, be sure to discuss with your doctor and dentist if you are on a bisphosphonate or are planning to start one.

Tell Your Rheumatology Provider

If undergoing an invasive procedure of the jaw (tooth extraction) or a history of malignancy and/or dental infections while on bisphosphonate therapy. Atypical fractures of the femur are rare complications of long-term (more than 5 years) bisphosphonate therapy. This may present as thigh pain without injury.

You should not take this medication if you have: kidney problems, low calcium levels, an inability to stand or sit upright for at least 30 minutes, or difficulty swallowing. An infusion with zoledronic acid may be preferred.

Do not take these medications if you are breastfeeding, pregnant, or may become pregnant.

Updated February 2025 by Rebecca Manno, MD, MHS, and reviewed by the American College of Rheumatology Committee on Communications and Marketing.

This information is provided for general education only. Individuals should consult a qualified healthcare provider for professional medical advice, diagnosis, and treatment of a medical or health condition.