What to advise a patient experiencing gastrointestinal upset with Alendronate (bisphosphonate) therapy?

From the Guidelines

For a patient experiencing stomach upset with alendronate, the most crucial step is to ensure they are taking the medication correctly to minimize gastrointestinal side effects. This involves taking the medication on an empty stomach first thing in the morning with a full glass of plain water (6-8 oz), remaining upright (sitting or standing) for at least 30 minutes after, and not consuming any food, beverages, or other medications during this time 1. Suggesting a switch to a weekly formulation if they're on a daily dose may also reduce gastrointestinal side effects while maintaining efficacy, as less frequent oral dosing has emerged as a trend to improve compliance 1. If symptoms persist despite proper administration, consider recommending alternative bisphosphonates like risedronate or ibandronate, which may be better tolerated, or non-bisphosphonate options such as denosumab or raloxifene. Temporary use of antacids (separated by at least 30 minutes from alendronate) may help relieve symptoms, but they should not be taken concurrently with the medication as they can interfere with absorption 1. Key considerations include:

• Ensuring proper administration technique to reduce gastrointestinal irritation
• Considering alternative formulations or medications if side effects persist
• Monitoring for and addressing any potential complications such as esophagitis or ulceration
• Being aware of the rare but potential risks associated with long-term bisphosphonate use, such as osteonecrosis of the jaw or atypical femur fractures, although these are more commonly associated with higher doses used in cancer treatment 1. Given the potential for gastrointestinal side effects, it's essential to weigh these against the benefits of alendronate in preventing bone loss and fractures, and to consider individual patient factors and alternative treatment options as needed.

From the FDA Drug Label

Instruct patients that if they develop symptoms of esophageal disease (such as difficulty or pain upon swallowing, retrosternal pain or new or worsening heartburn) they should stop taking alendronate sodium and consult their physician. Esophageal adverse experiences, such as esophagitis, esophageal ulcers and esophageal erosions, occasionally with bleeding and rarely followed by esophageal stricture or perforation, have been reported in patients receiving treatment with oral bisphosphonates including alendronate sodium.

If a patient experiences stomach upset with alendronate, the following steps should be taken:

• Stop taking the medication: If the patient develops symptoms of esophageal disease, such as difficulty or pain upon swallowing, retrosternal pain, or new or worsening heartburn, they should stop taking alendronate sodium.
• Consult a physician: The patient should consult their physician if they experience any symptoms of esophageal disease.
• Follow proper dosing instructions: To minimize the risk of esophageal problems, patients should be instructed to take alendronate sodium with a full glass of water (6-8 ounces) and to not lie down for at least 30 minutes after taking the medication 2.

From the Research

Stomach Upset with Alendronate

If a patient experiences stomach upset with Alendronate, the following steps can be taken:

• The risk of an adverse upper GI event can be decreased by following the dosing instructions, such as avoiding lying down for 30 minutes after taking the drug and taking the drug with a full glass of water 3.
• Once-weekly dosing may also decrease the risk of adverse GI tract events 3.
• If the patient is taking nonsteroidal anti-inflammatory drug (NSAID) therapy, it is essential to note that the risk of upper GI toxicity increases, but this incidence is no more than that observed with concurrent placebo and NSAID therapy 3.

Alternative Treatment Options

For patients with gastroesophageal reflux disease (GERD), the following treatment options can be considered:

• Antacids and acid inhibition, such as H2-receptor antagonists, can provide effective therapy for reflux symptoms 4.
• Proton pump inhibitors (PPIs) can be used for patients with severe esophagitis or reflux symptoms unresponsive to H2-receptor antagonists 4.
• Combination therapy with PPIs and H2-receptor antagonists may not provide any further benefit above that derived from PPIs alone 5.
• On-demand treatment with a PPI can give a high success rate with a fairly low dose, while an H2-blocker may have less success but can still satisfy almost half of the patients 6.