Alendronate Administration Before Anesthesia
Alendronate does not need to be held prior to anesthesia as there are no specific guidelines recommending discontinuation of bisphosphonates before surgical procedures requiring anesthesia. 1
Rationale for Continuing Alendronate
Bisphosphonates like alendronate are not included in any of the major anesthesiology guidelines regarding medications that should be held preoperatively. The American Society of Anesthesiologists (ASA) practice guidelines for preoperative fasting and pharmacologic agents do not mention bisphosphonates among medications that require discontinuation 2.
The primary considerations for medication management before anesthesia relate to:
- Risk of pulmonary aspiration
- Drug interactions with anesthetic agents
- Effects on hemodynamic stability
Alendronate does not significantly impact any of these concerns, as it:
- Does not affect gastric emptying or pH
- Has no known interactions with anesthetic medications
- Does not impact cardiovascular stability during anesthesia
Special Considerations
Dental Procedures Under Anesthesia
If the planned procedure involves dental work or oral surgery:
- Low-risk dental procedures do not require discontinuation of alendronate
- For moderate to high-risk dental procedures, the decision to stop alendronate should be made collaboratively between the oral surgeon and the primary care physician 1
- The risk of medication-related osteonecrosis of the jaw (ONJ) with alendronate is relatively low at standard osteoporosis doses compared to higher doses used for cancer treatment
Administration Timing if Continuing
If alendronate is continued before anesthesia:
- Oral alendronate should be taken on an empty stomach with a full glass of water
- The patient should remain upright for at least 30 minutes afterward
- The medication should be taken at least 2 hours before any other medications including preoperative medications 1
- For patients on weekly dosing (70 mg), scheduling can be adjusted to avoid taking the dose the day before or day of surgery to minimize potential GI side effects
Risks vs. Benefits
Benefits of Continuing Alendronate
- Maintains bone protection without interruption
- Avoids potential confusion in medication regimen
- Prevents potential rebound bone resorption
Potential Concerns (Though Not Evidence-Based)
- Theoretical risk of esophageal irritation if proper positioning cannot be maintained post-dose
- Potential for GI side effects (abdominal pain, nausea, dyspepsia) that might be confused with anesthesia side effects
Conclusion
The evidence does not support routinely holding alendronate prior to anesthesia. The ASA and Enhanced Recovery After Surgery (ERAS) guidelines do not include bisphosphonates in their recommendations for medications to discontinue before surgery 2. The primary focus should be on maintaining the standard administration protocols for alendronate if it is taken on the day of or before surgery.