A nurse is caring for a client who is taking alendronate to treat postmenopausal osteoporosis

Uses

Read the Medication Guide provided by your pharmacist before you start taking alendronate and each time you get a refill. Follow the instructions very closely to make sure your body absorbs as much drug as possible and to reduce the risk of injury to your esophagus. If you have any questions, ask your doctor or pharmacist.

Take this medication by mouth once a day, after getting up for the day and before taking your first food, beverage, or other medication. Take it with a full glass (6-8 ounces or 180-240 milliliters) of plain water. Swallow the tablet whole. Do not chew or suck on it. Then stay fully upright (sitting, standing, or walking) for at least 30 minutes and do not lie down until after your first food of the day. Alendronate works only if taken on an empty stomach. Wait at least 30 minutes (preferably 1 to 2 hours) after taking the medication before you eat or drink anything other than plain water.

Do not take this medication at bedtime or before rising for the day. It may not be absorbed and you may have side effects.

Calcium or iron supplements, vitamins, antacids, coffee, tea, soda, mineral water, calcium-enriched juices, and food can decrease the absorption of alendronate. Do not take these for at least 30 minutes (preferably 1 to 2 hours) after taking alendronate.

Take this medication regularly to get the most benefit from it. Remember to use it at the same time each morning. Talk to your doctor about the risks and benefits of long-term use of this medication.

Side Effects

Stomach pain, constipation, diarrhea, gas, or nausea may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor right away if you have any serious side effects, including: jaw/ear pain, increased or severe bone/joint/muscle pain, new or unusual hip/thigh/groin pain, swelling of joints/hands/ankles/feet, black/tarry stools, vomit that looks like coffee grounds.

This medication may rarely cause serious irritation and ulcers of the esophagus. If you notice any of the following unlikely but very serious side effects, stop taking alendronate and talk to your doctor or pharmacist right away: new or worsening heartburn, chest pain, pain or difficulty when swallowing.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US - Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Precautions

Before taking alendronate, tell your doctor or pharmacist if you are allergic to it; or to other bisphosphonates; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: disorders of the esophagus (such as esophageal stricture or achalasia), trouble swallowing, trouble standing or sitting upright for at least 30 minutes, low calcium levels, kidney problems, stomach/intestinal disorders (such as ulcers).

Some people taking alendronate may have serious jawbone problems. Your doctor should check your mouth before you start this medication. Tell your dentist that you are taking this medication before you have any dental work done. To help prevent jawbone problems, have regular dental exams and learn how to keep your teeth and gums healthy. If you have jaw pain, tell your doctor and dentist right away.

Before having any surgery (especially dental procedures), tell your doctor and dentist about this medication and all other products you use (including prescription drugs, nonprescription drugs, and herbal products). Your doctor or dentist may tell you to stop taking alendronate before your surgery. Follow all instructions about stopping or starting this medication.

This drug is not recommended for use in children. Studies have shown that many children who took this drug had severe side effects such as vomiting, fever, and flu-like symptoms.

Caution is advised if you are pregnant or planning to become pregnant in the future. Alendronate may stay in your body for many years. Its effects on an unborn baby are unknown. Discuss the risks and benefits with your doctor before starting treatment with alendronate.

It is unknown if this medication passes into breast milk. Consult your doctor before breast-feeding.

Interactions

See also How to Use section.

Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

Does Fosamax oral interact with other drugs you are taking?

Overdose

If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: severe stomach pain, painful heartburn, pain in the esophagus (chest pain), muscle weakness/cramps, mental/mood changes.

Notes

Do not share this medication with others.

Lifestyle changes that help promote healthy bones include increasing weight-bearing exercise, stopping smoking, limiting alcohol, and eating well-balanced meals that contain adequate calcium and vitamin D. You may also need to take calcium and vitamin D supplements. Consult your doctor for specific advice.

Laboratory and/or medical tests (X-rays, height measurement, blood mineral levels) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Missed Dose

If you miss a dose, skip the missed dose. Take your next dose at the regular time the following day. Do not double the dose to catch up.

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

Selected from data included with permission and copyrighted by First Databank, Inc. This copyrighted material has been downloaded from a licensed data provider and is not for distribution, except as may be authorized by the applicable terms of use.

CONDITIONS OF USE: The information in this database is intended to supplement, not substitute for, the expertise and judgment of healthcare professionals. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for you or anyone else. A healthcare professional should be consulted before taking any drug, changing any diet or commencing or discontinuing any course of treatment.

In this article, we cover the most important medications you need to know for osteoporosis, including bisphosphonates, selective estrogen receptor modulators, and a hypocalcemic agent. We'll start with some background on osteoporosis, including its pathophysiology.

The Nursing Pharmacology video series follows along with our Pharmacology Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Osteoporosis

Osteoporosis is a metabolic bone disorder that causes a lack of bone mass, leading to fragile bones and an increased risk of fractures.

If you'd like to learn more about osteoporosis, check out our Medical-Surgical flashcards for nursing students — osteoporosis is one of the musculoskeletal disorders covered, along with its pathophysiology, risk factors, signs/symptoms, diagnostics, treatment, and patient teaching; as well as an A&P refresher on bones in general.

Our bones have a process to maintain homeostasis called bone remodeling, and it involves bone cells called osteoblasts and osteoclasts.

Osteoblasts vs. osteoclasts

Osteoblasts build bones, while osteoclasts break down bones.

Osteoporosis happens when the rate of bone resorption (breakdown) by osteoclasts exceeds the rate of bone formation by osteoblasts.

Postmenopausal osteoporosis

Postmenopausal osteoporosis is the most common type of osteoporosis. Estrogen helps to stimulate bone growth and reduce the activity of osteoclasts, but a patient's estrogen levels drop precipitously when they hit menopause.

Bisphosphonates - Alendronate (Fosamax)

Alendronate (Fosamax) is a bisphosphonate that can be used for postmenopausal osteoporosis as well as Paget's disease of the bone,* which is a metabolic disorder that causes bones to be soft, structurally disorganized, and weak.

*There are at least 4 different Paget's diseases named after a 19th century doctor James Paget. In this video, Cathy says that Paget's disease is "a rare form of breast cancer," which is technically also true—but Alendronate, because it is an osteoclast inhibitor for bones, is used for Paget's disease of the bone, NOT Paget's disease of the breast. Whoops!

Mode of action

The mode of action of alendronate, along with other medications in the bisphosphonate class, is to prevent bone resorption by inhibiting the activity of osteoclasts. Remember that osteoclasts break down bones and take calcium from the bone into the bloodstream, and in the case of osteoporosis, osteoclasts are too active. Inhibiting osteoclasts helps to prevent further bone breakdown.

Alendronate's most important side effect to be aware of is esophagitis: inflammation of the esophagus which can cause pain, difficulty swallowing, and chest pain. Other side effects include GI upset, muscle pain, and visual disturbances.

Why can alendronate cause esophagitis?

The actual pill of Alendronate (and other bisphosphonate medications) can act as a local irritant to the gastrointestinal tract. It is hypothesized that bisphosphonates compromise the mucosal barrier, which can allow gastric acid through the epithelial lining, causing pain or a burning sensation. The patient teaching tips that follow help reduce the risk of esophagitis.

Patient teaching

Key patient teaching points for alendronate include the following.

• Patients should take alendronate on an empty stomach in the morning with a full glass of water.
• After taking alendronate, patients should sit upright or ambulate for at least 30 minutes to prevent esophageal ulceration—no lying down!
• Patients should increase their intake of calcium and vitamin D. Vitamin D is required for calcium absorption.
• Patients should engage in weight-bearing exercises to help preserve their bone mass.
• Patients' bone density should be monitored closely during therapy.

Selective estrogen receptor modulator - Raloxifene (Evista)

Raloxifene (Evista) is a selective estrogen receptor modulator used for postmenopausal osteoporosis. Raloxifene can also help reduce the risk for breast cancer.

Mode of action

Raloxifene's mode of action is to bind to estrogen receptors, which decreases bone resorption.

A selective receptor modulator is a drug that has different effects in different tissues. Raloxifene is unique because when it binds to estrogen receptors, it can reproduce the beneficial effects of estrogen in the bones (promoting bone growth and bone density maintenance) without the negative effects of estrogen on breast or endometrial tissue.

Another medication in this class is tamoxifen, used for breast cancer.

Side effects of raloxifene include an increased risk of embolic events (blood clots), like a pulmonary embolism, deep vein thrombosis, or stroke. Raloxifene can also cause hot flashes or leg cramps.

Black box warning

Raloxifene carries a black box warning due to its risk of causing blood clots.

Patient teaching

If you have a patient taking raloxifene, encourage them to increase their intake of calcium and vitamin D, and to do weight-bearing exercises.

Nursing care

If you have a patient taking raloxifene, remember to monitor their bone density.

Hypocalcemic agent - Calcitonin (Miacalcin)

Calcitonin is a naturally-occurring hormone secreted by the thyroid that decreases blood calcium levels. The manufactured form of calcitonin (Miacalcin) is a hypocalcemic agent used for postmenopausal osteoporosis, as well as hypercalcemia.

Hypercalcemia is seen in hyperparathyroidism, which is a disorder of the parathyroid glands resulting in hypersecretion, or excess secretion, of parathyroid hormone (PTH) resulting in excess blood calcium levels. Hyperparathyroidism is one of the important disorders covered in our Medical-Surgical flashcards.

Mode of action

Calcitonin's mode of action is to prevent bone resorption by inhibiting the activity of osteoclasts. Remember that osteoclasts' primary job is to break down bone, so to retain bone density, we want to inhibit those osteoclasts. Calcitonin also increases renal excretion of calcium.

Side effects of calcitonin include GI upset, which is very common, and if administered intranasally, nasal irritation or dryness.

Patient teaching

The patient teaching tips you need to remember with calcitonin are the same tips with the other osteoporosis medications we've covered here.

• Patients should be getting adequate calcium and vitamin D in their diet or through supplements.
• Patients should do weight bearing exercises.

If you have a patient taking calcitonin, it is important to monitor their bone density.

Full Transcript

Okay, in this video we are going to continue with our coverage of key musculoskeletal medications that you should know. And specifically in this video, we will be covering medications used for osteoporosis. If you are following along with your cards, I am on card 93 in our Pharmacology Flashcards edition 2.0.

Okay, so let's talk about first medication class which are bisphosphonates. And the key medication that falls within this class in alendronate.

Alendronate can be used for postmenopausal osteoporosis as well as Paget's disease, which is a rare form of breast cancer.

The mode of action of alendronate is to prevent bone resorption by inhibiting the activity of osteoclasts. So normally, osteoclasts are breaking down the bone and taking calcium from the bone into the bloodstream. And we don't want that, right? We want that calcium to stay in the bones. So that's what alendronate helps to do, right? It prevents the osteoclasts from breaking it down, so we are keeping that calcium in the bones.

In terms of the side effects, the key side effect that's going to be important for you to remember is esophagitis. So this is where we have inflammation of the esophagus. Other side effects include GI upset, muscle pain and visual disturbances.

There are some key teaching points that you need to provide your patient and they are listed on this card here, card 93 in bold and red. So definitely review those things.

We want to advise our patient to take this on an empty stomach in the morning with a full glass of water, and then after they take this medication, we do not want the patient lying down because that can really result in that esophagitis. So after they take this medication, they need to sit upright or ambulate for 30 minutes to prevent that esophageal ulceration that can occur. So that's going to be very important.

Also we're going to want to encourage our patient to increase their intake of calcium and vitamin D, because vitamin D is needed for calcium absorption and they should also engage in weight-bearing exercises to help preserve their bone mass. And then we're going to want to monitor their bone density regularly during therapy.

So my little trick for remembering this, if you look at the word alendronate, I think alen, some guy name Alan drones on and on about his esophagitis. The other little trick that you might use to remember this is after you take your alendronate, maybe go out and fly your drone, right? Like you're usually standing up when you fly your drone. Maybe you're sitting up but usually not laying down flying your drone, right? So if you fly your drone for 30 minutes after you take alendronate, then that will help prevent that esophageal ulceration.

Right. Now let's talk about a selective estrogen receptor modulator which is raloxifene. So raloxifene is used for post-menopausal osteoporosis. It can also help reduce the risk for breast cancer.

The mode of action is that it binds estrogen receptors which decreases bone resorption.

In terms of the side effects, the key side effect I would remember includes an increased risk for embolic events. So this includes things like a DVT, a PE, or a stroke. This medication does carry a black box warning for just this reason because of the increased risk for clots. In addition, hot flashes and leg cramps are also common.

For teaching, you want to make sure your patient is increasing their intake of calcium and vitamin D, and we want to encourage weight-bearing exercises as well.

And then we want to monitor the patient's bone density.

In terms of how I remember this medication, if you look at the name raloxifene, and you look at it backwards, it has fix and then the letter O. So I think that raloxifene will fix your osteoporosis. So it's kind of spelled backwards there, and that helps me to remember what it's for.

Okay. Finally, let's talk about a hypocalcemic agent, meaning an agent that helps to bring down calcium levels in the blood. So the medication that falls within this class is calcitonin.

Calcitonin is used for post-menopausal osteoporosis as well as hypercalcemia, meaning we have too much calcium in the bloodstream.

It works to prevent bone resorption by inhibiting the activity of osteoclasts. It also increases renal excretion of calcium.

In terms of the side effects, GI upset is common and if you are taking it through the intranasal route, then nasal irritation or dryness is also common.

In terms of teaching, we're going to do the same type of teaching. Make sure you're getting enough calcium and vitamin D, weight-bearing exercises, and monitoring the patient's bone density will be important.

In terms of how I remember this medication, if you look at the word calcitonin, you think ‘tone it down,’ meaning tone down that calcium. Bring those calcium levels down in the bloodstream.

So that is it for our osteoporosis medications. In my next video, we will cover medications for gout. So hang in there with me and we'll get through these meds together!