Esophagitis with bisphosphonates

The most common bisphosphonate adverse effects are nausea, abdominal pain, and dyspepsia. Esophageal, gastric, or duodenal irritation, perforation, ulceration, or bleeding may occur when administration directions are not followed or when bisphosphonates are prescribed for patients with contraindications. The most common adverse effects of IV bisphosphonates include fever, flu-like symptoms, and local injection-site reactions. Osteonecrosis of the jaw occurs rarely if it develops, oral chlorhexidine washes, systemic antibiotics, and systemic analgesics are used based on severity. 

Take drugs that have a direct irritant effect on the esophageal mucosa with plenty of liquid if they cannot be avoided (bisphosphonates, tetracyclines, quinidine, potassium chloride, iron salts, aspirin, nonsteroidal antiinflammatory drugs). 

Bisphosphonates irritate esophageal and gastric mucus membranes tablets should be swallowed with a reasonable amount of water (250 mL) and the patient should keep in an upright position for 30 min following drug intake. 

The risk of severe esophageal adverse experiences appears to be greater in patients who lie down after taking bisphosphonates or who fail to swallow it with a full glass (6 to 8 oz) of water, or who continue to take bisphosphonates after developing symptoms suggestive of esophageal irritation. 

Use caution when bisphosphonates are given to patients with active upper Gl problems (such as dysphagia, esophageal diseases, gastritis, duodenitis, or ulcers). Etidronate therapy has been withheld from patients with enterocolitis because diarrhea is seen in some patients, particularly at higher doses. 

Use the ER tablets and transdermal system with caution in patients who have gastroesophageal reflux or who are concurrently taking drugs (such as bisphosphonates) that can cause or exacerbate esophagitis. 

With the exception of the possible development of a hypervitaminosis associated with high-dose administration of vitamin D2 or D3, the compounds discussed in this chapter are relatively safe. Allergic reactions to the injection of calcitonin and PTH have occurred and chronic use of some bisphosphonates has been associated with the development of osteomalacia. The principal side effects of intravenous bisphosphonates are mild and include low-grade fever and transient increases in serum creatinine and phosphate levels. Oral bisphosphonates are poorly absorbed and can cause esophageal and gastric ulceration. They should be taken on an empty stomach the individual must remain upright for 30 minutes after ingestion. 

For most seniors, bisphosphonates are the preferred agents. Esophageal dysfunction should be clinically ruled out, and the patient s ability to adhere to the complex administration process must be assured before beginning therapy. Once-weekly dosing is usually preferred. Although bisphosphonates are not recommended in patients with renal insufficiency (creatinine clearance <35 mL/min), some clinicians are using lower-dose (alendronate 35 mg once weekly) therapy. Because many seniors do not have medication coverage, cost issues need to be addressed. 

Pamidronate, a second-generation bisphosphonate, is 100-fold more potent than etidronate (Fig. 35.7) (6). It has been approved for the treatment of hypercalcemia of malignancy, for Paget s disease, and for osteolytic bone metastases of breast cancer and osteolytic lesions of multiple myeloma. When used to treat bone metastases, pamidronate decreases osteoclast recruitment, decreases osteoclast activity and increases osteoclast apoptosis (53). Erosive esophagitis has been reported with the use of pamidronate sodium. 

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