Indications: Treatment of postmenopausal osteoporosis and osteoporosis in men. Prevention and treatment of corticosteroid-induced osteoporosis in postmenopausal women not receiving hormone replacement therapy.

Cautions: upper gastro-intestinal disorders (dysphagia, symptomatic oesophageal disease, gastritis, duodenitis, or ulcers—see also under contra-indications and side effects); history (within 1 year) of ulcers, active gastro- intestinal bleeding, or surgery of the upper gastro- intestinal tract; correct disturbances of calcium and mineral metabolism (e.g. vitamin-D deficiency, hypocalcaemia) before starting and monitor serum- calcium concentration during treatment; consider dental check-up before initiating bisphosphonate (risk of osteonecrosis of the jaw, exclude other causes of osteoporosis; atypical femoral fractures.

Contra-indications: abnormalities of oesophagus and other factors which delay emptying (e.g. stricture or achalasia), hypocalcaemia.

Renal impairment: Avoid if eGFR less than 35 ml/minute/1.73 m2.

Pregnancy: Avoid

Breast-feeding: no information available

Side Effects: oesophageal reactions, abdominal pain and distension, dyspepsia, regurgitation, melaena, diarrhoea or constipation, flatulence, musculoskeletal pain, headache; rarely rash, pruritus, erythema, photosensitivity, uveitis, scleritis, transient decrease in serum calcium and phosphate; nausea, vomiting, gastritis, peptic ulceration, hypersensitivity reactions (including urticaria and angioedema), atypical femoral fractures with long-term use, myalgia, malaise, and fever at initiation of treatment; very rarely severe skin reactions (including Stevens-Johnson syndrome), osteonecrosis of the jaw.

Oesophageal reactions: Severe oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions) have been reported; patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain.

Dose: Treatment of postmenopausal osteoporosis, 10 mg daily or 70 mg once weekly. Treatment of osteoporosis in men, 10 mg daily. Prevention and treatment of corticosteroid-induced osteoporosis in postmenopausal women not receiving hormone replacement therapy, 10 mg daily.

Counselling: Tablets should be swallowed whole with plenty of water while sitting or standing; to be taken on an empty stomach at least 30 minutes before breakfast (or another oral medicine); patient should stand or sit upright for at least 30 minutes after taking tablet.