What are the contraindications for Bisphosphonates?

From the Guidelines

Bisphosphonates are contraindicated in patients with esophageal emptying disorders, inability to sit upright, and severe renal impairment (creatinine clearance less than 30 mL/min) due to the risk of pill esophagitis and renal insufficiency 1.

Contraindications

• Hypersensitivity to bisphosphonates
• Esophageal abnormalities that delay esophageal emptying, such as stricture or achalasia
• Inability to stand or sit upright for at least 30 minutes after oral administration
• Severe renal impairment (creatinine clearance less than 30 mL/min) for intravenous bisphosphonates
• Hypocalcemia before starting treatment, as bisphosphonates can further lower calcium levels

Precautions

• Dental examination and preventive dentistry intervention are recommended before treatment with intravenous bisphosphonates to reduce the risk of osteonecrosis of the jaw (ONJ) 1
• Renal function monitoring is necessary before each dose of intravenous bisphosphonates, and dose reduction or discontinuation may be required if renal function is reduced 1
• Calcium and vitamin D supplementation is recommended unless otherwise contraindicated, and patients should be advised to take oral bisphosphonates and calcium at least 2 hours apart to allow for maximum absorption 1
• Ocular symptoms such as pain or loss of vision should be promptly evaluated by an ophthalmologist, as they may be due to serious inflammatory conditions such as uveitis or scleritis 1

From the Research

Contraindications for Bisphosphonates

• Severe renal impairment (creatinine clearance <30 or <35 mL/min) is a contraindication for the use of bisphosphonates 2, 3
• Bisphosphonates should be used with caution in patients with moderate to severe chronic kidney disease (CKD), as they may be associated with a modest increased risk of CKD progression 4
• Other potential contraindications or precautions for bisphosphonate use include:
  • Gastrointestinal contraindications or intolerance 3
  • Malabsorption or inability to comply with dosing requirements 3
  • History of osteonecrosis of the jaw, atypical femur fractures, atrial fibrillation, or esophageal cancer, as these conditions may be associated with bisphosphonate use 5

Special Considerations

• Patients with CKD stages 3b to 5 should be carefully evaluated before initiating bisphosphonate therapy, as they may be at increased risk of CKD progression 4
• Elderly, frail, osteoporotic patients with renal impairment may be able to receive intravenous bisphosphonate therapy without long-term renal function decline, but should be closely monitored 2
• The concept of a "drug holiday" has emerged, whereby patients who are not at high risk for fracture may be able to discontinue bisphosphonate therapy for a period of time while still benefiting from antifracture efficacy 5