Contraindications to Alendronic Acid
Alendronic acid is absolutely contraindicated in patients with esophageal abnormalities that delay emptying (such as stricture or achalasia), inability to stand or sit upright for at least 30 minutes, hypocalcemia, and hypersensitivity to any component of the product. 1
Absolute Contraindications
Esophageal and Upper GI Abnormalities
- Esophageal stricture or achalasia are absolute contraindications because these conditions delay esophageal emptying and dramatically increase the risk of severe esophageal ulceration and perforation 1
- Patients with cirrhosis who have portal hypertension and esophageal varices should avoid oral alendronate due to the potential to precipitate variceal hemorrhage from esophageal ulceration 2
Inability to Comply with Dosing Instructions
- Patients who cannot stand or sit upright for at least 30 minutes after taking the medication are contraindicated from using alendronate 1
- This includes bedridden patients, those with severe mobility limitations, or patients with conditions preventing upright posture 1
Metabolic Contraindications
- Hypocalcemia must be corrected before initiating alendronate therapy, as bisphosphonates can worsen existing hypocalcemia 1
- Vitamin D deficiency should be corrected prior to bisphosphonate initiation, particularly for IV therapy, as deficiency may attenuate efficacy and increase risk of bisphosphonate-related hypocalcemia 2, 3
Hypersensitivity
- Known hypersensitivity to alendronate or any component of the formulation is an absolute contraindication 1
Severe Renal Impairment (Relative Contraindication)
- Alendronate is not recommended in patients with creatinine clearance less than 35 mL/min 1
- Bisphosphonates with creatinine clearance less than 30 mL/min can increase serum creatinine and may rarely cause acute renal failure 2
- For patients with CrCl <60 mL/min, consider switching to denosumab as an alternative 3
Critical Clinical Pitfalls to Avoid
Esophageal Safety
- Do not prescribe alendronate to patients who cannot follow strict dosing instructions: swallow tablets whole with 6-8 ounces of plain water at least 30 minutes before the first food, drink, or medication of the day 1
- Patients must remain upright (standing or sitting) for at least 30 minutes after taking the medication and until after eating food 1, 4
- These precautions are non-negotiable and reduce the risk of esophagitis and esophageal ulceration 4
Pre-Treatment Assessment
- Complete a dental examination and any necessary dental work before initiating bisphosphonate therapy to reduce osteonecrosis of the jaw risk 2, 3
- Ensure adequate calcium intake (800-1000 mg/day) and vitamin D (800 IU/day) before and during treatment 3, 5
- Measure serum calcium and vitamin D levels; correct deficiencies before starting therapy 2
Drug Interactions
- Calcium supplements, antacids, or oral medications containing multivalent cations interfere with absorption of alendronate and must be taken at a different time 1
- Bisphosphonates should be taken 0.5-2 hours before consumption of food and other drugs, and at a different time than calcium supplements as calcium binds and inactivates bisphosphonates 2