From the Guidelines
Bisphosphonates are contraindicated in patients with severe renal impairment, hypocalcemia, uncorrected vitamin D deficiency, and active upper gastrointestinal problems, as well as those with a history of hypersensitivity to bisphosphonates or osteonecrosis of the jaw. The use of bisphosphonates should be avoided in patients with certain conditions that increase the risk of adverse effects, including severe renal impairment (creatinine clearance <30 mL/min) as stated in 1, where intravenous bisphosphonates can increase serum creatinine and may rarely cause acute renal failure. Patients with active upper gastrointestinal problems such as esophagitis, gastritis, ulcers, or difficulty swallowing should avoid oral bisphosphonates like alendronate, risedronate, and ibandronate due to the risk of esophageal irritation, as mentioned in 1. Some key points to consider when prescribing bisphosphonates include:
- Correcting hypocalcemia before starting therapy, as hypocalcemia can be worsened by bisphosphonates, especially in patients with uncorrected vitamin D deficiency, as noted in 1 and 1.
- Ensuring adequate calcium and vitamin D supplementation, with approximately 600 mg calcium per day and 400 IU vitamin D3 per day, as recommended in 1.
- Performing dental evaluation before starting treatment due to the risk of osteonecrosis of the jaw, particularly in those with poor dental health or requiring invasive dental procedures, as mentioned in 1.
- Avoiding the use of bisphosphonates in patients with severe renal impairment, as they can exacerbate renal insufficiency, as stated in 1 and 1.
- Considering alternative treatments or dose adjustments for patients with moderate renal impairment, as recommended in 1. It is essential to weigh the benefits and risks of bisphosphonate therapy in each patient, taking into account their individual medical history and current health status, to minimize the risk of adverse effects and ensure the best possible outcome, as supported by the guidelines and recommendations in 1 and 1.
From the FDA Drug Label
Pamidronate disodium is contraindicated in patients with clinically significant hypersensitivity to pamidronate disodium or other bisphosphonates. The main contraindication to biphosphonates is:
- Hypersensitivity to the drug or other bisphosphonates 2 No other direct contraindications are mentioned in the provided drug labels.
From the Research
Contraindications to Bisphosphonates
- Renal failure: Patients with renal failure are at a higher risk of developing hypocalcemia and renal complications when treated with bisphosphonates 3, 4, 5.
- Malnutrition: Malnourished patients are at a higher risk of developing hypocalcemia when treated with bisphosphonates 3.
- Hypoparathyroidism: Patients with unrecognized hypoparathyroidism are at a higher risk of developing hypocalcemia when treated with bisphosphonates 6.
- Vitamin D deficiency: Patients with vitamin D deficiency are at a higher risk of developing hypocalcemia when treated with bisphosphonates 4, 6.
- Renal insufficiency: Patients with renal insufficiency are at a higher risk of developing renal complications when treated with bisphosphonates 5.
Precautions
- Monitoring of serum creatinine is advised before and after intravenous dosing or periodically with oral bisphosphonates 5.
- Assessment of renal function, vitamin D status, and parathyroid gland function is recommended before bisphosphonate treatment 4, 6.
- Calcium and vitamin D supplementation may be necessary during bisphosphonate treatment 4.