Bisphosphonates

Question 1

Bisphosphonates - indications

Answer 1

1. Alendronic acid is used as the first-line drug treatment option for patients at risk of osteoporotic fragility fractures.
2. Treatment of severe hypercalcaemia of malignancy
3. For patients with myeloma and breast cancer with bone metastases - reduce the risk of pathological fractures, cord compression and the need for radiotherapy or surgery.
4. First-line treatment of metabolically active Paget’s disease - reducing bone turnover and pain.

Question 2

Bisphosphonates - MOA

Answer 2

Bisphosphonates have a similar structure to naturally occurring pyrophosphate: hence they are readily incorporated into bone.

Bisphosphonates accumulate in osteoclasts, where they inhibit activity and promote apoptosis.

The net effect is a reduction in bone loss and improvement in bone mass.

Question 3

Bisphosphonates - adverse effects

Answer 3

• oesophagitis (when taken orally)

- hypophosphataemia.

Question 4

Bisphosphonates - adverse effects (rare but serious)

Answer 4

osteonecrosis of the jaw (more likely with high-dose IV therapy) - good dental care is important to minimise risk

atypical femoral fracture (especially if on long term treatment)

Question 5

Bisphosphonates - in terms of osteonecrosis of the jaw, what do you need to advise the patient about?

Answer 5

Good dental care is important to minimise the risk of this.

Go to the dentist if you notice any loose teeth, jaw pain/swelling

Question 6

Bisphosphonates - contraindications

Answer 6

✗severe renal impairment
✗hypocalcaemia
✗upper gastrointestinal disorders

Question 7

Bisphosphonates - cautions

Answer 7

• smokers
• patients with major dental disease

WHY? Due to risk of jaw osteonecrosis

Question 8

Osteoporosis - how do you explain to a patient what osteoporosis is?

Answer 8

Osteoporosis is a condition that weakens the bones and makes them more fragile and more likely to break – usually do not have any symptoms until the bones become weaker and break

Question 9

Osteoporosis - how do you explain to patients how to treat this condition with bisphosphonates?

• how will this treatment work?
• how do i take the medication?

Answer 9

The treatment will work by treating and preventing broken bones
Preventing broken bones will work by taking medication that will strengthen the bones and therefore make them less likely to break

Medication called alendronic acid
o Take 1 tablet (70mg) once a week
o Take tablet first thing in the morning before eating/drinking – body absorb better
o Stay sitting or standing for 30 minutes after taking – prevent throat irritation
o Advise patients to see their dentist before and during bisphosphonate treatment.

Question 10

Osteoporosis - when treating osteoporosis with bisphosphonates, what needs to be checked and corrected prior to starting treatment?

Answer 10

In osteoporosis, check and replace calcium and vitamin D before treatment

Question 11

Bisphosphonates - interactions

Answer 11

Bisphosphonates bind calcium.
Absorption is therefore reduced if taken with: 
- calcium salts (including milk)
- antacids
- iron salts