Bisphosphonate Therapy

Bisphosphonates are a group of medicines used to treat osteopenia or osteoporosis, which are conditions associated with thin or fragile bones that are at increased risk for fracture. The medications help strengthen the bones and prevent future bone fractures. Patients with low bone density or a history of low-energy trauma fractures are recommended to take these medications. Disorders such as Paget’s disease and cancer that have spread (metastasized) to the bone are other indications for use.

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. Bone cells in our bodies are constantly being slowly removed and replaced with new bone cells. As we age and in certain diseases, the bone is actually being removed or damaged faster than your body is able to replace it which leads to thin weakened bones. Bisphosphonates work by reducing the turnover of bone which lowers the risk of fracture.

How to Take It

Alendronate, risedronate, and ibandronate are oral medications taken either daily, weekly, or monthly. For osteoporosis treatment, alendronate is given 70 mg by mouth once a week, and risedronate is given by mouth 35 mg weekly or 150 mg monthly. Ibandronate is given orally, 150 mg once a month. These medications must be taken first thing in the morning on an empty stomach with an 8oz 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. Zoledronic acid is administered at your doctor’s office or at an infusion center. The dose is 5 mg given once a year. The duration of treatment varies for each patient.

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.

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. It is recommended that you have a good dental exam prior to starting these medications. Atypical fractures of the femur have been associated with long-term bisphosphonate therapy. Often presents as thigh pain. Notify your doctor if you develop side effects from the medications.

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. Infusion with zoledronic acid may be preferred.

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

Updated March 2023 by David Waldburg, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee.

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