Bisphosphonate Comparison Table and Clinical Pearls

Bisphosphonates are frequently used in the management of osteoporosis. They are often the go-to agent for this condition. Below we provide a bisphosphonate comparison table and I also wanted to highlight some of the most important clinical pearls that we should teach our patients and colleagues.

Oral administration of bisphosphonates is not something to take lightly. These drugs have strict requirements. Oral bisphosphonates should be administered first thing in the morning and prior to any food or medications. In addition, it should be taken with a full glass of water with the patient remaining upright for 30 minutes. This helps prevent esophagitis. Avoiding coadministration with food and other medications helps aid in maximizing absorption of the drug.

Another challenge with bisphosphonates is the length of use. 5 years is the magic number with oral bisphosphonates. That is the time to reassess if longer-term therapy is warranted or not. This decision is usually based upon the risk for future fracture when looking at the patient’s previous history.

Renal function is important to monitor with the use of bisphosphonates. Zoledronic acid is contraindicated if renal function is below 35 mls/min. Using oral bisphosphonates is controversial in patients with a GFR of less than 30 mls/min. In practice, I’ve seen it done. The challenge is that there isn’t a lot of clinical literature either supporting the safety of use or demonstrating harm if used in patients who have a GFR of less than 30 mls/min.

Bisphosphonate Comparison Table

AlendronateRisedronateIbandronateZoledronic acidPamidronate
Brand nameFosamax, BinostoActonel, AtelviaBonivaReclast, ZometaAredia
FDA approvalOsteoporosis in males and postmenopausal females. Treatment of glucocorticoid-induced osteoporosis. Paget disease.Osteoporosis in males and postmenopausal females. Treatment and prevention of glucocorticoid-induced osteoporosis. Paget disease.Osteoporosis in postmenopausal females.Osteoporosis in males and postmenopausal females. Bone metastases. Hypercalcemia of malignancy. Paget diseaseHypercalcemia of malignancy. Bone metastases or osteolytic lesions. Paget disease.
CrCl<35mL/min: use not recommended<30mL/min: use not recommended<30mL/min: use not recommended<35mL/min: use contraindicated  <30mL/min: contraindicated or dose-adjusted depending on disease
Route of administrationOrallyOrallyOrally or IVIVIV
Dosage formSolution, tablet, effervescent tabletTabletTablet, IV solutionIV solution, IV concentrateIV solution
FrequencyWeekly or dailyWeekly or dailyMonthly or every 3 monthsYearly or every other yearDepends on disease Minimum: weekly
Osteoporosis prevention dosing35 mg once a week or 10mg daily5mg once daily or 35mg once weekly or 150mg once monthlyOral: 150mg once monthly5mg once every 2 yearsN/A
Osteoporosis treatment dosing70mg once a week or 10mg daily35mg once a week or 5mg daily or 150mg once a monthOral: 150mg once a month IV: 3mg every 3 months5mg once every 12 monthsN/A
Duration of therapy5-10 years5-10 yearsOral: 5-10 years IV: 3 years3-6 yearsNot known
Bisphosphonate Comparison Table put together by Madison Bonn, PharmD, Candidate

What other issues have you seen come up with bisphosphonates?

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Written By Eric Christianson

December 12, 2021

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