Treatment length

Bisphosphonate therapy should be reviewed after five years of treatment with alendronate, risedronate and ibandronate, and after three years on zoledronate. Continuation beyond this can be recommended for certain patients – namely anyone over 75 years of age, with a history of hip or vertebral fracture or one or more fragility fractures during treatment, or on long-term glucocorticoid treatment – but there is no evidence for prolonging beyond 10 years. Longer-term management should only occur after specialist input and on a case-by-case basis.

Strontium ranelate is generally prescribed long-term, but with regular reviews. Denosumab should not be stopped without specialist review as there is usually a need for a bisphosphonate to be prescribed to counteract the rapid bone loss that can occur.

Side-effects 

The patient information leaflet will highlight common side-effects so draw attention to this. The more frequently experienced side-effects are listed in Table 1 and patients on oral bisphosphonates should stop taking their medicine and seek medical advice if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, and pain when swallowing or behind the sternum. 

Some of the more common side-effects – mild GI symptoms, aches and pains with bisphosphonates, nausea and diarrhoea with strontium ranelate – are more likely to occur soon after starting treatment but will usually subside. For all bisphosphonates, patients should be advised to report any hip, thigh or groin pain (which could be a sign of an atypical femoral fracture), ear pain or discharge (due to the risk of osteonecrosis of the external auditory canal).

Bisphosphonates and denosumab increase the risk of osteonecrosis of the jaw so patients should report oral symptoms such as dental mobility, pain or swelling, and be encouraged to maintain good oral hygiene, have regular dental check-ups, and avoid invasive dental procedures, if possible. For the same reason of side-effects impacting the jaw, tobacco use should be warned against.

Strontium ranelate increases the risk of myocardial infarction, so patients should be advised to promptly report any signs of heart or circulatory problems such as angina symptoms, a rise in blood pressure or symptoms of a blood clot. They should also be undergoing an assessment every six to 12 months for their individual risk factors for cardiovascular disease. Strontium ranelate can also cause severe allergic reactions so patients should seek immediate medical advice if they develop a skin rash.