Men's Osteoporosis Support GroupBisphosphonate-associated adverse events Hormones (Athens). 2009 Apr-Jun;8(2):96-110. Bisphosphonate-associated adverse events. Papapetrou PD. PMID: 19570737. This is an interesting review of the nitrogen-containing oral bisphosphonates, such as, alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). The free full-text article is available online here. Adverse events topics covered include: Upper gastrointestinal tract adverse events, Renal toxicity, Ocular adverse events, Acute phase response, Hypocalcaemia and secondary hyperparathyroidism, Musculoskeletal pain, Osteonecrosis of the jaw, Atrial fibrillation, Atypical fractures of the femoral diaphysis, and Miscellaneous adverse events. I have covered most of the topics discussed in this review in Updates and Newsletters on the Men's Osteoporosis website, often with multiple articles. But there are a few topics that I want to either reemphasize or mention for the first time. The nice aspect of this review article is that it has all the topics in one short paper with references should you want more information. So I hope you'll read the full article since I won't be covering everything Papapetrou discusses. The article mentions the following conditions as exclusions from taking oral bisphosphonates: upper GI tract bleeding within the past five years requiring hospitalization or transfusion; documented recurrent or recent ulcer disease (two episodes in the preceding five years or one episode in the preceding 12 months); experience of esophageal or gastric varices; or using medication daily for dyspepsia. Additionally disorders of esophageal motility, such as stricture or achalasia, were also excluded. Also mentioned is that Barrett’s esophagus should be a contraindication for bisphosphonates. Renal toxicity seems primarily to be an issue with the intravenous bisphosphonates. But if you have documented renal disease you should discuss this with your physician if you are starting bisphosphonates for osteoporosis. I have mentioned this problem in previous Updates, but never by the name Acute Phase Response (AFR). It is mainly associated withe use of intravenous bisphosphonates, is short term, associated with the first dose, is dose-dependent, and, ". . . is characterized by fever, sometimes with rigors, and influenza-like symptoms such as fatigue, malaise, myalgia, arthralgia and bone pain." The author notes, "Mild to moderate AFR may also occur with the initial exposure to once-weekly or once-monthly doses of oral bisphosphonates, that is, more often than with the daily formulations of the drugs." Hypocalcaemia and secondary hyperparathyroidism generally occur shortly after starting bisphosphonate therapy, and are normally asymptomatic in those taking oral bisphosphonates, but may not be in those on intravenous forms. The article notes, "The bisphosphonate-induced hypocalcaemia and secondary hyperparathyroidism can be avoided or attenuated by the administration of adequate vitamin D and calcium supplements, starting about two weeks before the administration of the bisphosphonate." So this is a case highlighting the importance of taking calcium and vitamin D supplements to avoid these potential problems. Editor's comments. I had never seen Barrett's esophagus (BE) as a contraindication for oral bisphosphonates before, so I wanted to highlight that in this Update. Actually when I check using online search engines I notice that it has been mentioned in other articles, I must have just missed it. From my reading this doesn't appear to be something that has been discovered via controlled clinical trials with BE patients, but is more of a logical conclusion that oral bisphosphonates might aggravate this condition, which can lead to serious esophageal cancer. The question is what alternatives are there for BE patients? One option that occurs to me is that there are several once-monthly oral bisphosphonate options available now, including Boniva and Actonel. These have been included in clinical trials to assure they effectiveness on a once-monthly dose regimen. And logically Fosamax should do equally as well. This recent Update, and others, discuss the once-monthly oral bisphosphonate dosing method. The other options would include the intravenous bisphosphonates, and the non-bisphosphonates that are FDA approved to treat osteoporosis. To see a list of all approved osteoporosis medications, see the topic at the National Osteoporosis Foundation website. Basically, for men, the two non-bisphosphonate options are calcitonin, such as Miacalcin, or teriparatide (Forteo). If you have BE and osteoporosis, discuss the options with your physician. Logically it seems that once-monthly bisphosphonates are a viable option, but that is a decision you and your care provider need to make. Follow up EGD (Esophagogastroduodenoscopy) to verify that no problems are resulting from the oral bisphosphonate use is likely warranted and should also be discussed with your care provider.
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