What patient education is necessary for a patient taking Fosamax (alendronate) to minimize side effects and ensure safe use?

Patient Education for Fosamax (Alendronate)

Critical Administration Instructions to Prevent Esophageal Injury

Patients must take alendronate with a full glass (6-8 ounces) of plain water immediately upon arising in the morning, at least 30 minutes before any food, beverage, or other medication, and must remain fully upright (sitting or standing) for at least 30 minutes after taking the tablet. 1

Specific Dosing Requirements

• Take the medication first thing in the morning after an overnight fast with plain water only—even orange juice or coffee markedly reduces absorption 1
• Swallow the tablet whole with a full glass of water (6-8 ounces) to facilitate delivery to the stomach 1
• Do not chew or suck on the tablet due to potential for oropharyngeal ulceration 1
• Never take alendronate at bedtime or while still in bed 1
• Remain upright (sitting or standing) for at least 30 minutes and until after eating the first food of the day 1
• Failure to follow these instructions increases the risk of severe esophageal problems, including ulcerations and chemical esophagitis 1, 2

If a Weekly Dose is Missed

• Take one dose on the morning after remembering 1
• Do not take two doses on the same day 1
• Return to taking one dose once weekly on the originally scheduled day 1

Essential Supplementation Requirements

All patients taking alendronate must receive adequate calcium (1,000-1,200 mg daily) and vitamin D (400-800 IU daily) supplementation if dietary intake is inadequate. 3, 1

• The American College of Oncology emphasizes this supplementation is mandatory for all patients 3
• Inadequate supplementation may reduce treatment efficacy and increase risk of hypocalcemia 4
• The National Comprehensive Cancer Network recommends checking serum 25(OH)D levels before starting therapy, with a target level ≥30 ng/mL 4
• For vitamin D deficiency (levels <30 ng/mL), ergocalciferol 50,000 IU weekly for 8 weeks is recommended, then recheck levels 4

Warning Signs Requiring Immediate Medical Attention

Stop taking alendronate immediately and contact your physician if you develop difficulty or pain with swallowing, retrosternal pain, or new or worsening heartburn. 1

• These symptoms may indicate esophageal injury, which can be severe and includes ulcerations with discolored exudate, narrowed lumen, and hemorrhagic mucosa 5, 2
• Esophagitis risk is increased in patients who take the medication with little water, lie down after taking it, continue taking it after symptoms develop, or have preexisting esophageal disorders 2

Lifestyle Modifications for Optimal Bone Health

• Engage in regular weight-bearing exercise 3, 1
• Stop smoking completely 3, 1
• Limit alcohol consumption to two or fewer units daily 3
• Maintain adequate calcium intake through diet and supplements 3, 1

Rare but Serious Long-Term Complications

Osteonecrosis of the Jaw (ONJ)

• This is a rare complication with incidence less than 1 to 28 cases per 100,000 person-years 4
• Risk increases after 2 years of therapy 3
• Maintain excellent dental hygiene and inform your dentist that you are taking bisphosphonates 3

Atypical Femoral Fractures

• Incidence ranges from 3.0 to 9.8 cases per 100,000 patient-years 4
• Report any new thigh or groin pain to your physician 4

Contraindications and Special Precautions

• Do not take alendronate if you have abnormalities of the esophagus that delay esophageal emptying 3, 4
• Do not take if you cannot sit or stand upright for at least 30 minutes 3, 4
• Alendronate is contraindicated in patients with hypocalcemia 4
• Not recommended for patients with chronic kidney disease and GFR <35 mL/min/1.73 m² 4
• Patients at increased risk of aspiration should not receive alendronate solution 3

Treatment Duration and Monitoring

• The American Geriatrics Society recommends that after 5 years of therapy, consideration should be given to drug holidays or dose reduction, as fracture protection may persist for up to 5 years after stopping 4
• Bone mineral density with vertebral fracture assessment or spinal x-ray should be performed every 1-2 years during long-term therapy 3
• The need for continued therapy should be reevaluated after 3-5 years of use 4