Bisphosphonates have been extensively used for the treatment of osteoporosis and other metabolic bone diseases. One of the major side effects of their use has been mucosal injury to the upper gastrointestinal tract.


Gastrointestinal mucosal injury associated with the bisphosphonates:

(1) pill-induced esophagitis, ranging from simple irritation to ulceration

(2) peptic ulceration in the stomach or duodenum, especially those with a primary amino side chain (alendronate or pamidronate)


These complications may present as abdominal discomfort or pain.


Risk factors for esophageal or gastric mucosal injury:

(1) elderly (age > 65 years)

(2) concurrent therapy with aspirin or other NSAID

(3) debilitated bed-ridden patients

(4) use of solid pills rather than microencapsulated formulations (a pill allows a high concentration of drug to form locally)

(5) taking while recumbent with a small amount of liquid

(6) pre-existing esophagitis, gastritis or peptic ulceration


If one or more of these risk factors is present, then:

(1) Consider the use of parenteral therapy.

(2) If an oral formulation is used then:

(2a) A microencapsulated or similar formulation should be used.

(2b) The patient should take the oral formulation with plenty of liquid while erect and should stay erect for some time after ingestion.

(2c) The patient should be closely monitored for signs of toxicity.


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