What are the contraindications to oral bisphosphonates?

Contraindications to Oral Bisphosphonates

Oral bisphosphonates are contraindicated in patients with esophageal emptying disorders, inability to sit upright for at least 30 minutes after taking the medication, and in those with creatinine clearance less than 30 mL/min. 1

Absolute Contraindications

• Esophageal disorders that delay emptying (e.g., achalasia, stricture, dysmotility) 1
• Inability to remain upright for at least 30 minutes after taking medication 1, 2
• Severe renal impairment (creatinine clearance <30 mL/min) 1
• Hypocalcemia (must be corrected before starting therapy) 1
• Vitamin D deficiency (should be corrected before initiating treatment) 1
• Hypersensitivity to bisphosphonates 3

Relative Contraindications and Precautions

Gastrointestinal Concerns

• Active upper GI disease (esophagitis, gastritis, duodenitis, ulcers) 4, 5
• History of Barrett's esophagus 3
• Concurrent use of NSAIDs or anticoagulants (increased risk of GI adverse events) 5

Dental/Oral Health

• Planned invasive dental procedures (should be completed before starting therapy when possible) 2
• Poor oral hygiene (increases risk of osteonecrosis of the jaw) 2
• Active oral infections (should be treated before starting therapy) 2

Special Populations

• Pregnancy and lactation (bisphosphonates should be avoided) 1
• Women of childbearing potential should use effective contraception during treatment 1

Clinical Considerations for Specific Patient Groups

For Adults <40 Years

• Oral bisphosphonates should only be considered in those with:
  • History of osteoporotic fracture
  • Continuing glucocorticoid treatment (≥6 months at ≥7.5 mg/day)
  • Hip or spine BMD Z-score <-3
  • Bone loss ≥10%/year at hip or spine 1

For Women of Childbearing Potential

• Must not be planning pregnancy during treatment period
• Must use effective birth control
• Oral bisphosphonates preferred over IV bisphosphonates or denosumab due to potential fetal risks 1

For Patients with Renal Impairment

• Oral bisphosphonates have better renal safety than IV formulations in patients with lower creatinine clearance
• Still contraindicated when creatinine clearance <30 mL/min 1

Administration Requirements to Prevent Adverse Effects

1. Take on an empty stomach with a full glass of water (180-240 mL)
2. Remain upright (sitting or standing) for at least 30 minutes after taking
3. No food or other medications for at least 30 minutes after taking
4. Ensure adequate calcium and vitamin D intake, but take calcium supplements at least 2 hours after oral bisphosphonate 2

Monitoring Recommendations

• Dental evaluation before starting therapy
• Renal function before and periodically during treatment
• Serum calcium and vitamin D levels before and during treatment
• Bone mineral density reassessment after 1-2 years of therapy 2

Common Pitfalls in Prescribing Oral Bisphosphonates

• Failing to assess renal function before prescribing
• Not providing proper administration instructions to patients
• Prescribing to patients who cannot remain upright after taking medication
• Not evaluating dental health before initiating therapy
• Not correcting vitamin D deficiency or hypocalcemia before starting treatment 1, 2

By carefully screening for these contraindications and providing proper administration instructions, the risk of serious adverse effects from oral bisphosphonates can be minimized while maintaining their effectiveness in treating osteoporosis.