Alendronate Does Not Need to Be Discontinued Prior to Anesthesia
Alendronate should be continued through the perioperative period and does not require discontinuation before anesthesia. Simply omit the scheduled dose on the day of surgery if the patient will be nil-by-mouth, then resume normal dosing once the patient can follow proper administration instructions postoperatively.
Why Alendronate Continuation is Safe
No perioperative guidelines recommend stopping alendronate before surgery. The most recent comprehensive perioperative medication management guidelines from multiple societies (Association of Anaesthetists, Royal College of Anaesthetists, Centre for Perioperative Care) address medications requiring cessation—including GLP-1 receptor agonists, SGLT2 inhibitors, and various analgesics—but make no mention of bisphosphonates requiring discontinuation 1.
The absence of alendronate from perioperative cessation guidelines is deliberate and evidence-based:
- Alendronate has an extremely long skeletal half-life with sustained bone effects lasting months to years after discontinuation, making short-term perioperative interruption pharmacologically irrelevant 2
- The drug is not metabolized and is eliminated solely through renal excretion and skeletal uptake, with no hepatic metabolism that could be affected by anesthetic agents 2
- Oral bioavailability is only 0.7% in the fasted state, meaning the drug has minimal systemic exposure and negligible interaction potential with anesthetic medications 2
Practical Perioperative Management
On the day of surgery, simply omit the alendronate dose because the patient will be fasting and unable to follow the required administration protocol (upright position for 30 minutes, empty stomach, full glass of water) 3, 4, 5.
Resuming Alendronate Postoperatively
Resume alendronate once the patient can eat and drink normally and follow proper administration instructions 3:
- Patient must be able to sit or stand upright for at least 30 minutes after taking the medication 3, 4, 5
- Patient must take medication with 6-8 ounces (180-240 mL) of plain water on an empty stomach 3, 5
- Patient must wait at least 30 minutes before consuming any food, beverages, or other medications 3, 4
For patients on weekly dosing (70 mg once weekly), missing one dose due to surgery has no clinical consequence given the drug's prolonged skeletal retention 6, 2.
Critical Distinction from Other Perioperative Medications
Alendronate differs fundamentally from medications that DO require perioperative cessation:
- SGLT2 inhibitors must be stopped the day before surgery due to ketoacidosis risk, requiring a minimum 36-48 hour gap 1
- GLP-1 receptor agonists require cessation due to delayed gastric emptying and aspiration risk 1
- Denosumab should never be stopped without immediate bisphosphonate replacement due to rebound fracture risk 3, 7
Alendronate has none of these perioperative safety concerns and therefore continues through the surgical period 3.
Common Pitfalls to Avoid
Do not confuse alendronate's upper GI administration requirements with a need for perioperative cessation. The esophageal irritation risk from alendronate is related to improper administration technique (inadequate water, lying down too soon), not to anesthesia or surgery itself 5.
Do not stop alendronate days or weeks before surgery "to be safe." This provides no benefit and may unnecessarily interrupt osteoporosis treatment in high-risk patients 3, 7. The drug's skeletal effects persist for months after discontinuation due to its incorporation into bone matrix 2.
Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation continues perioperatively to maintain treatment efficacy 3, 8.