Bisphosphonates
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2023-076898 (Published 21 August 2024) Cite this as: BMJ 2024;386:e076898
- Emma Billington, assistant professor of medicine1,
- Fariba Aghajafari, associate professor2,
- Elaine Skulsky, osteoporosis patient representative3,
- Gregory A Kline, clinical professor of medicine14
- 1Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada T2T5C7
- 2Department of Family Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary
- 3Calgary, Canada
- 4Dr. David Hanley Osteoporosis Centre, Cumming School of Medicine, University of Calgary
- Correspondence to: G A Kline gakline{at}ucalgary.ca
What you need to know
For patients with osteoporosis, assess patient eligibility for treatment with bisphosphonate therapy by using a fracture risk assessment tool
Oral therapy should be taken on an empty stomach with high adherence
Check renal function prior to prescribing intravenous therapy
Treat for at least five years (oral) or three years (annual intravenous) before consideration of hiatus
A shared decision making approach is highly valued by patients who are considering treatment
A 70 year old white woman presented to her general practitioner for her annual check-up. She weighs 62 kg and is 164 cm tall. She is a tobacco user (20 pack-year) with prior wrist fracture three years ago after a fall on ice. Dietary history revealed low calcium intake, and she does not take vitamin D supplements. Her mother had a hip fracture at age 74 years. Given these risk factors, you order a bone density scan (DEXA), which shows a femoral neck T-score of−2.6. A fracture risk assessment tool (FRAX) estimates she has a 10-year hip fracture risk of 18% with 10-year major fracture risk of 36%. You consider prescribing a bisphosphonate.
How often are bisphosphonates prescribed and how do they work?
From February 2023 to January 2024, UK primary care data for England showed that about 6.2 million prescriptions for oral bisphosphonates (alendronate or risedronate) were made.1 Almost all patients who are treated for postmenopausal osteoporosis are prescribed oral bisphosphonates,2 and in a review of nearly half a million treated patients from seven European countries with osteoporosis, 84% were prescribed bisphosphonates.3 There are four licensed preparations commonly available worldwide, alendronate, risedronate, ibandronate, and zoledronate (zoledronic acid).
Bisphosphonates have been used since 1995, when alendronate received regulatory approval for the treatment of postmenopausal osteoporosis.4 Since then, bisphosphonates have been introduced for a range of additional indications including Paget disease of bone, prevention of skeletal-related events in …
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