Examples

Generic Name	Brand Name
alendronate	Fosamax
pamidronate	Aredia
risedronate	Actonel
zoledronic acid	Reclast

You take some bisphosphonates, such as alendronate and risedronate, by mouth (orally). Others, such as pamidronate and zoledronic acid, are given intravenously.

How It Works

Bisphosphonates decrease the number and activity of bone cells (osteoclasts) to reduce the breakdown of bone tissue. Bone has a more normal structure after bisphosphonate therapy.¹

Why It Is Used

Bisphosphonates decrease bone tissue breakdown. This leads to more normal bone structure and then to decreased pain and risk of fracture.

Doctors may use bisphosphonates to help prevent complications in people with Paget's disease who do not yet have symptoms. They also use bisphosphonates before surgery to decrease the activity of Paget's disease, so there is less risk of bleeding and complication from the surgery.

How Well It Works

Most often, bisphosphonates are the first medicines doctors use to treat Paget's disease and control its symptoms.

Bisphosphonates slow the rate of bone tissue breakdown and increase bone thickness in the spine and hip. This slows the progression of the disease. Bisphosphonates can also reduce symptoms that Paget's disease can cause, such as bone pain, ringing in the ears, dizziness, and numbness or weakness.

Bisphosphonates may take several months to become fully effective. Effects of bisphosphonates tend to last even after the person stops taking the medicine. On occasion, a person may need additional courses of the medicine to treat a return to active disease.

Reduction in laboratory markers such as alkaline phosphatase shows that the medicine is working to reduce the activity of Paget's disease. Some people eventually become resistant to one medicine, so it doesn't work as well to control their symptoms. When this happens, another bisphosphonate or another medicine may be effective.¹

Side Effects

Side effects are uncommon if the medicine is taken as directed, but may include:

• Severe heartburn.
• Belly pain and irritation of the throat (esophagus).
• Upset stomach (nausea).
• Diarrhea, constipation, and increased gas.
• Flu-like symptoms including headache and pain in muscles and joints (especially if you take intravenous medicine).
• Increased bone pain. (This tends to be related to the dose of medicine used.)

For the best results and to reduce the risk of irritation to your esophagus if you take bisphosphonates by mouth:

• Take bisphosphonates in the morning with a full glass of water at least 30 minutes before eating a meal, drinking a beverage, or taking any other medicine.
• Sit or stand (don't lie down) for at least 30 minutes after taking a bisphosphonate. This helps prevent heartburn.
• Do not take a bisphosphonate late in the day if you forgot to take it in the morning.

Serious problems with bone healing, particularly after dental surgery, have been found in some people taking bisphosphonates.² If you are taking bisphosphonates and need dental surgery, talk with your doctor.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

People generally use oral bisphosphonates for 2 to 6 months to treat Paget's disease.

Bisphosphonates you take by mouth can cause damage to the throat (esophagus).³ You should not use them if you have a malfunction of the nerves of the esophagus (achalasia), an inflammation (esophagitis) or narrowing (esophageal stricture) of the esophagus, or a hiatal hernia.

You should not take these medicines immediately before or just after meals, because food slows the absorption of the medicine. How soon before or after a meal you take the medicine varies with the medicine. Talk with your doctor or nurse, and follow instructions carefully.

Take bisphosphonates with water, not milk, because milk also decreases the absorption of the medicine.

Your doctor or nurse may suggest that you take calcium and vitamin D supplements while you are taking bisphosphonates. This can help keep your bones strong. Do not take bisphosphonates within 2 hours of taking antacids or medicines high in calcium, magnesium, iron, or aluminum (such as Mylanta or Tums).

Pamidronate and zoledronic acid are given intravenously. People who cannot take the medicine by mouth have used these medicines successfully.

Bisphosphonates are often used in cycles. They nearly always make Paget's disease inactive, sometimes for years or decades. But in some people Paget's disease becomes active again. You use bisphosphonates until pain decreases and lab tests show normal results. Then you take a break from the medicine for about 3 months or until lab tests show that Paget's disease is active again.⁴

Bisphosphonates are better than calcitonin for slowing or eliminating disease activity.¹

Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.

References

Citations

1. Altman RD (2005). Paget's disease of bone. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 2, pp. 2543–2557. Philadelphia: Lippincott Williams and Wilkins.
2. Woo S-B, et al. (2006). Systematic review: Bisphosphonates and osteonecrosis of the jaw. Annals of Internal Medicine, 144(10): 753–761.
3. Favus MJ, Vokes TJ (2008). Paget disease and other dysplasias of bone. In AS Fauci et al., eds., Harrison's Principles of Internal Medicine, 17th ed., vol. 2, pp. 2408–2416. New York: McGraw-Hill.
4. Fitzgerald PA (2008). Paget's disease of bone (Osteitis deformans) section of Endocrine disorders. In LM Tierney et al., eds., Current Medical Diagnosis and Treatment, 47th ed., pp. 1000–1001. New York: McGraw-Hill.