Preoperative Medication Management

Introduction to Bisphosphonate Use

Bisphosphonates do not require discontinuation before surgery, as per the American Society of Anesthesiologists (ASA) and Enhanced Recovery After Surgery (ERAS) guidelines, with evidence not supporting routine holding of alendronate prior to anesthesia 1, 2, 3

Patients starting bisphosphonates should undergo preventative dentistry intervention to reduce the risk of medication-related osteonecrosis of the jaw (ONJ) 4
Vitamin D supplementation with 600-800 IU/day is recommended for patients starting bisphosphonates, according to the American College of Rheumatology 5
Patients with vitamin D deficiency may require higher replacement doses (50,000 IU weekly for 6 weeks) before starting therapy, as suggested by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis 6
Regular dental check-ups are necessary during treatment with bisphosphonates to monitor for oral infections and periodontal disease, as recommended by the National Comprehensive Cancer Network 4
Patients on bisphosphonate therapy should undergo laboratory testing, including monitoring of serum phosphorus and magnesium levels, as recommended by the American College of Rheumatology 5, 7

Alendronate is contraindicated in patients with creatinine clearance less than 35 mL/min, and dose adjustment is not necessary for patients with GFR between 35-60 mL/min, but periodic monitoring of renal function is required, as recommended by the American Journal of Kidney Diseases 8
Oral bisphosphonates are contraindicated in patients with esophageal emptying disorders, inability to sit upright for at least 30 minutes after taking the medication, severe renal impairment (creatinine clearance <30 mL/min), hypocalcemia, and vitamin D deficiency, as recommended by the National Comprehensive Cancer Network 9
Pregnancy and lactation are contraindications for oral bisphosphonate therapy, and women of childbearing potential should use effective contraception during treatment, as advised by the American College of Rheumatology 5

Bisphosphonate treatment should be considered for discontinuation after 5 years unless the patient has strong indications for continued therapy, as suggested by the Annals of Internal Medicine 10
The decision to stop alendronate before a dental procedure should be made collaboratively between the oral surgeon and the primary care physician, with the oral surgeon taking the lead on the final decision, according to the MASCC/ISOO/ASCO clinical practice guideline 11
Low-risk dental procedures do not require discontinuation of alendronate, while moderate to high-risk procedures may require temporary discontinuation based on factors such as duration of bisphosphonate therapy and presence of other risk factors, as recommended by the MASCC/ISOO/ASCO clinical practice guideline 11
Patients at very high fracture risk should continue bisphosphonate therapy, while those with moderate to low fracture risk may be considered for a drug holiday, as recommended by the National Comprehensive Cancer Network and the American Society of Clinical Oncology 9, 10

Patients with cancer and bone metastases should continue bisphosphonate therapy throughout the course of the disease, as recommended by the European Society for Medical Oncology and the American Society of Clinical Oncology 12, 13

Alendronate should be taken on an empty stomach with a full glass of water, remaining upright for at least 30 minutes afterward, and avoiding food or other medications during this time to minimize adverse effects, supported by the EULAR/EFORT guidelines 14, 9, 15, 16
Calcium and vitamin D supplementation is recommended for patients taking bisphosphonates, with calcium taken at least 2 hours after oral bisphosphonate, and regular monitoring is essential during bisphosphonate therapy, including reassessment of BMD after 1-2 years, monitoring of bone turnover markers, and regular evaluation of fracture risk using risk assessment tools, as recommended by the American Society of Clinical Oncology 7, 10
Treatment should be resumed if any of the following occur during the drug holiday: new fracture, significant BMD decline (>5% at hip), increase in fracture risk factors, or T-score falls to ≤ -2.5, as recommended by the National Comprehensive Cancer Network 17