Bisphosphonates for Postmenopausal Osteoporosis | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network
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JAMA Patient Page
January 5, 2021

Bisphosphonates for Postmenopausal Osteoporosis

Author Affiliations
  • 1University of Minnesota, Minneapolis VA Health Care System, Minneapolis
JAMA. 2021;325(1):96. doi:10.1001/jama.2020.2923

Bisphosphonates are medications prescribed to treat postmenopausal osteoporosis.

What Is Osteoporosis?

Osteoporosis causes thinning of the bones, causing them to be more likely to break (fractures). Although osteoporosis can affect men, older women past menopause are at highest risk because of their low estrogen levels. Osteoporotic fractures most often happen at the hip, spine, and wrist. They typically result from falling, but sometimes even a mild stress (eg, bending over) can cause a fracture.

Who Should Be Treated for Osteoporosis?

Women at highest fracture risk, such as women with osteoporosis diagnosed by bone density testing or women with a personal history of hip or spine fracture, are most likely to benefit from osteoporosis medications. Women receiving osteoporosis medications should have an adequate intake of calcium (1000-1200 mg daily) and vitamin D (600-800 IU daily).


Most women being treated for osteoporosis receive a bisphosphonate such as alendronate, risedronate, zoledronate, or ibandronate. Because bisphosphonates reside in bone for a long time, they continue to have effects on bone even after they are discontinued. Alendronate and risedronate are taken orally, ibandronate is available as an oral medication or as an intravenous injection, and zoledronate is administered as an intravenous injection. Oral bisphosphonates need to be taken first thing in the morning with a full 8-oz glass of plain water. After taking an oral bisphosphonate, one should remain upright (sitting or standing) and wait 30 to 60 minutes before lying down, drinking, or eating. This helps ensure that the medication is absorbed and reduces the chance of side effects.

Benefits and Harms of Bisphosphonates

All bisphosphonates lower the risk of spine fractures. Alendronate, risedronate, and zoledronate are most commonly recommended because they also lower the risk of nonspine fractures, including hip fractures. Stomach upset is a possible side effect of oral bisphosphonates, but the risk of this problem is markedly reduced by closely following the medication instructions. Very rare potential harms include loss of blood supply to the jawbone (osteonecrosis of the jaw) and an unusual fracture of the thigh bone (atypical femoral fracture). Osteonecrosis of the jaw most commonly occurs after invasive dental procedures such as tooth extraction; women taking bisphosphonates should consult their doctor to determine whether to stop the medication before having this type of procedure. Taking bisphosphonates for more than 5 years may increase risk of having an atypical femoral fracture. For many women, limiting the treatment period to 5 years or less maximizes the benefits of taking bisphosphonates in reducing the chance of having typical osteoporotic fractures while minimizing the risk of having an atypical femoral fracture.

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Article Information

Conflict of Interest Disclosures: Dr Ensrud reported receipt of grants from Merck.

Source: Ensrud KE, Crandall CJ. Bisphosphonates for postmenopausal osteoporosis. JAMA. 2019;322(20):2017-2018. doi:10.1001/jama.2019.15781