Contraindications and Precautions for IV Bisphosphonates in Osteoporosis Treatment

Absolute Contraindications

The American College of Rheumatology recommends that IV bisphosphonates should not be administered to patients with severe renal impairment (creatinine clearance <30 mL/min) due to risk of increased serum creatinine and potential acute renal failure 1
The American College of Rheumatology recommends that uncorrected hypocalcemia or vitamin D deficiency must be corrected before initiating IV bisphosphonate therapy as hypocalcemia has been reported in patients with unrecognized vitamin D deficiency 1
The American College of Rheumatology recommends that IV bisphosphonates should be avoided in pregnant women or women planning pregnancy due to potential fetal harm 1

The American College of Rheumatology recommends that IV bisphosphonates should be used only in women of childbearing potential who are at high risk of fracture when oral bisphosphonates and teriparatide are not appropriate 2, 3
The American College of Rheumatology recommends that treatment should be initiated only after a discussion about potential fetal harms in the event of an unplanned pregnancy 2, 3
The American College of Rheumatology recommends that patients with organ transplants on glucocorticoids who have a glomerular filtration rate ≥30 mL/min can be treated according to age-related guidelines 2, 3
The American College of Rheumatology recommends that an evaluation by a metabolic bone disease expert is recommended for all patients with a renal transplant before initiating IV bisphosphonate therapy 2, 3
The American College of Rheumatology recommends that denosumab is not recommended for transplant patients due to lack of adequate safety data on infections in adults treated with multiple immunosuppressive agents 2, 3
The American College of Rheumatology recommends that in children ages 4-17 years with osteoporotic fractures who are continuing glucocorticoid treatment, IV bisphosphonates should only be used if oral treatment is contraindicated 2, 4
The American College of Rheumatology recommends that oral bisphosphonates are preferred over IV formulations in children due to less potential harm 2, 4

The American College of Rheumatology recommends that patients requiring invasive dental procedures should delay starting IV bisphosphonate therapy if possible 1
The American College of Rheumatology recommends that poor oral hygiene and recent dental extraction are risk factors for osteonecrosis of the jaw (ONJ) in patients on bisphosphonate therapy 1

The American College of Rheumatology recommends that for patients with renal impairment, oral bisphosphonates may be considered as they appear to have better renal safety 1
The American College of Rheumatology recommends that for women of childbearing potential who cannot take oral bisphosphonates, teriparatide is recommended as a second-line therapy 2, 3
The American College of Rheumatology recommends that for patients with severe renal impairment, denosumab (except in transplant patients) or raloxifene may be considered as alternative treatments 1

The American College of Rheumatology recommends that for adults continuing glucocorticoid treatment who have had a fracture after ≥18 months of oral bisphosphonate treatment or significant bone mineral density loss (≥10%/year), consider switching to another class of osteoporosis medication (teriparatide or denosumab) 4
The American College of Rheumatology recommends that IV bisphosphonates may be considered if treatment failure is judged to be due to poor absorption or poor medication adherence to oral bisphosphonates 4