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Clinical Review State of the Art Review

Bisphosphonates for the prevention and treatment of osteoporosis

BMJ 2015; 351 doi: (Published 02 September 2015) Cite this as: BMJ 2015;351:h3783
Treating osteoporosis with bisphophonates infographic
Click here to see an interactive graphic, showing patient assessment, treatment pathways and decisions at each stage.

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Author's Reply

We appreciate the expertise and additional perspective provided to readers by Minisola and colleagues. Monoclonal gammopathy of undetermined significance is of skeletal significance and for which bisphosphonate therapy may be considered.

Alendronate sodium oral solution is available in the United States in a 70 mg/75 mL formulation. We were unaware of the alendronic acid solution 70 mg/100 mL product commercialized in the United Kingdom. We could not find data comparing the tolerability of these products with other bisphosphonate oral formulations noting the high prevalence of baseline gastrointestinal complaints in those who might be prescribed bisphosphonates.1

We wrote “Before starting bisphosphonates it is necessary to assess for and correct hypocalcemia and vitamin D deficiency” with the data of Bertoldo et al. in mind yet appreciate the additional attention Minisola and colleagues bring to this issue in their reply.2

The writers allude to “treatment failure” and decisions regarding continuation of bisphosphonate therapy. Until more definitive data is available to support the utility of continued bisphosphonate therapy in such patients, we share the opinions expressed by Diez-Perez et al and the framework their position paper provides to doctors facing this dilemma.3

1. Cryer B and Bauer DC. Oral bisphosphonates and upper gastrointestinal tract problems: What is the evidence? Mayo Clin Proc 2002 Oct; 77:1031-43.
2. Bertoldo F, Pancheri S, Zenari S,et al. Serum 25-hydroxyvitamin D levels modulate the acute-phase response associated with the first nitrogen-containing bisphosphonate Infusion. J Bone Miner Res 2010;25:447–54
3. Diez-Perez A, Adachi JD, Agnusdei D, et al. Treatment failure in osteoporosis. Osteoporos Int 2012;23:2769-74.

Competing interests: No competing interests

19 October 2015
Kurt A. Kennel
Consulting Endocrinologist
Spyridoula Maraka
Mayo Clinic
Rochester, MN, USA