Can Alendronate (bisphosphonate) be taken with milk or should it be taken with plain water in the morning?

Alendronate Administration Requirements

Alendronate must be taken with plain water only—never with milk or any other beverage—as milk and other drinks dramatically reduce absorption and render the medication ineffective. 1

Why Plain Water Is Mandatory

• The FDA label explicitly states that alendronate must be taken "with plain water the first thing upon arising for the day at least 30 minutes before the first food, beverage, or medication of the day." 1
• Even orange juice or coffee markedly reduces alendronate absorption, making the medication therapeutically ineffective. 1
• Milk contains calcium, which binds to and inactivates bisphosphonates, completely preventing absorption. 2
• Bisphosphonates have extremely poor bioavailability (less than 5% absorption under optimal conditions), so any interference with absorption eliminates therapeutic benefit. 2

Exact Administration Protocol

To ensure proper absorption and minimize esophageal injury risk, patients must follow this precise sequence: 1

• Take alendronate immediately upon arising in the morning, before any food, beverage, or other medication
• Swallow the tablet whole with a full glass (6-8 ounces/180-240 mL) of plain water only 1, 3
• Do not chew or suck on the tablet, as this causes oropharyngeal ulceration 1
• Remain upright (sitting or standing) for at least 30 minutes after swallowing 1, 3
• Do not lie down until after eating the first food of the day 1
• Take calcium supplements at a different time of day, as calcium binds and inactivates bisphosphonates 2

Critical Safety Considerations

Failure to follow these instructions significantly increases the risk of severe esophageal complications, including ulceration and erosive esophagitis. 1, 3

• Esophagitis risk factors include: taking alendronate with little or no water, lying down during or after ingestion, continuing medication after symptom onset, and having preexisting esophageal disorders 3
• In postmarketing surveillance, 26% of esophageal adverse events were categorized as serious or severe, with 16% requiring hospitalization 3
• Patients should discontinue alendronate immediately and contact their physician if they develop difficulty swallowing, pain upon swallowing, retrosternal pain, or new/worsening heartburn 1

Alternative Options for Patients Who Cannot Comply

For patients unable to take oral alendronate with plain water or remain upright for 30 minutes, switching to intravenous bisphosphonates (zoledronic acid 5 mg annually or ibandronate 3 mg every 3 months) completely bypasses the upper GI tract and eliminates these administration requirements. 4

• Intravenous formulations should be considered for those with esophageal disorders, swallowing difficulties, or inability to comply with strict dosing requirements 2, 4
• Before initiating any bisphosphonate, correct vitamin D deficiency to achieve levels >32 ng/mL to prevent bisphosphonate-related hypocalcemia 2, 4
• Complete necessary dental work before starting bisphosphonates, as dental surgery is the most consistent risk factor for osteonecrosis of the jaw 2, 4