Bisphosphonate Therapy

Bisphosphonates are medications used to treat osteopenia and osteoporosis, conditions in which bones become thin, weak, and more likely to fracture. These medications help reduce bone breakdown by inhibiting osteoclast activity, which slows bone loss and improves bone strength, ultimately lowering the risk of fractures of the spine, hip, and other bones.

Bisphosphonates are commonly prescribed for patients with osteoporosis, low bone density, prior fragility fractures, or individuals at high fracture risk, including patients receiving long-term glucocorticoid (steroid) therapy. They are also used in certain other bone disorders such as Paget’s disease of bone and cancers that have spread to the bone.

Common bisphosphonate medications include oral agents such as alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). Intravenous (IV) formulations include zoledronic acid (Reclast/Zometa), ibandronate, and pamidronate.

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 May 2026 by Howard Yang, MD, RhMSUS, 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.