Osteoporosis and bisphosphonates: how do you take them properly?

The exact steps for taking alendronate, risedronate or ibandronate, what to do if you miss a dose and which effects to watch for.

For a bisphosphonate to work, take it as soon as you get up, on an empty stomach and with a full glass of tap water; then stay upright and wait at least 30 minutes before breakfast, any other drink or other medicines (60 minutes for monthly ibandronic acid). That is what their leaflets say.

These are very specific rules and it is easy to skip one without realising, especially with a weekly or monthly tablet. We explain the steps, the differences between the most common bisphosphonates and how to fit them in with the rest of your medication.

How do you take a bisphosphonate step by step?

Oral bisphosphonates are very poorly absorbed and only work if they reach an empty stomach; they can also irritate the oesophagus if the tablet gets stuck on the way down. That is why the leaflet insists on taking them on an empty stomach, with plain water and without lying down afterwards. These are the steps in the leaflet for weekly alendronic acid:

1. On your chosen day of the week, take it as soon as you get up, before any food, drink or other medicine.
2. Swallow it whole with a full glass of tap water (no less than 200 ml). Do not use mineral water, coffee, tea, juice or milk.
3. Do not chew it, suck it or let it dissolve in your mouth.
4. Stay upright (sitting, standing or walking) for at least 30 minutes, and do not lie down until after your first meal of the day.
5. Wait at least 30 minutes before having breakfast, any other drink or other medicines.

If you take it with breakfast or with coffee, much of the medicine is not absorbed: it is as if you had not taken it.

Does anything change depending on which bisphosphonate I have been prescribed?

Yes: the frequency, the amount of water and the waiting time change. Weekly alendronic acid and risedronate ask you to wait at least 30 minutes; monthly ibandronic acid asks you to wait 60 minutes. Always follow the leaflet for your specific medicine.

Never take a double dose to make up. Because these are weekly or monthly medicines, they are easy to forget: mark the day on your calendar or set an alarm with the medicine's name. You will find more ideas in alarms and apps so you never forget your medication.

What about calcium, vitamin D, coffee and my other medicines?

Everything else comes after the waiting time. The alendronate leaflet states that antacids, calcium supplements and vitamins should be taken later, not at the same time, because they reduce its absorption.

• Calcium and vitamin D: they are often prescribed alongside the bisphosphonate. Ask your doctor or pharmacist what time of day suits you best to take them.
• Coffee, tea, juice or milk: only after the 30 minutes (or 60, if it is ibandronate).
• Other medicines taken on an empty stomach: if you also take levothyroxine or another medicine that must be taken fasting, ask your pharmacist to set the order of your doses for that day. We explain this in how to take levothyroxine properly.

Which effects should I watch for and how long does treatment last?

The most important thing is to watch your oesophagus and mouth. The alendronate leaflet warns that it can cause irritation or ulcers of the oesophagus and that these effects can get worse if you keep taking it once they appear: if you notice pain on swallowing, new heartburn or chest pain, talk to your doctor before your next dose.

• Mouth and jaw: tell your doctor if you notice pain, swelling or sores in your mouth or jaw, or loose teeth. Have regular dental check-ups and tell your dentist you take a bisphosphonate before an extraction or implant.
• Thigh, hip or groin: new pain in that area should be checked, because of the rare risk of atypical thigh bone fractures.
• Ear: very rarely, ear pain, discharge or infection.

As for duration, the NHS says most people take alendronic acid for at least 3 to 5 years, after which the doctor reviews the benefits and risks of continuing. Do not stop it on your own: it is a decision to make with your doctor.

A practical example: Pilar and her Sunday tablet

Take the case of Pilar, 66, recently retired, with osteoporosis and an underactive thyroid. Her doctor prescribes weekly alendronic acid on top of her daily levothyroxine and a calcium and vitamin D supplement. In the first few weeks she kept forgetting the alendronate or taking it with her coffee.

1. She chooses Sunday, the day she gets up without rushing, and sets a weekly alarm saying "alendronate: water and 30 minutes upright".
2. She asks her pharmacist how to combine the two fasting tablets, and is given an order and waiting times for that day.
3. She leaves the calcium for later, at the time she has been advised.
4. She books a dental check-up and tells her dentist she has started a bisphosphonate.

With a fixed day and a clear routine, Pilar takes her tablet correctly without having to think about it every week.

How can IMA Health help with a weekly or monthly treatment?

Medicines that are not taken every day are the ones most often forgotten or mixed up. At IMA Health we coordinate with a specialised pharmacy that prepares your medication by day and time of each dose, including weekly ones, we deliver it to your home and we provide personalised follow-up.

To find out more about this system, read what an SPD is and how it makes things easier.

Sources

• CIMA (AEMPS): Ácido alendrónico semanal Cinfamed 70 mg package leaflet (in Spanish)
• CIMA (AEMPS): Risedronato semanal Cinfa 35 mg package leaflet (in Spanish)
• CIMA (AEMPS): Ácido ibandrónico Cinfa 150 mg package leaflet (in Spanish)
• NHS: Common questions about alendronic acid

This article is for information only and does not replace advice from your doctor or pharmacist.