Fosamax (Alendronate): Risks, Side Effects & Precautions

Alendronate (Fosamax) is a first-line bisphosphonate for osteoporosis. Generally well-tolerated, but serious adverse effects exist.

Common Side Effects (≥1–5%)

• GI: Heartburn, nausea, abdominal pain, dysphagia, esophagitis, ulcer.
• Musculoskeletal: Bone/joint/muscle pain (can be severe, delayed onset).
• Flu-like symptoms (first dose).

Serious / Rare Risks

Monitoring & Duration

• Reassess need after 3–5 years ("drug holiday" for low-risk).
• DEXA every 1–2 years; monitor height loss, back pain (vertebral fracture).
• Dental exam before starting; maintain oral hygiene.

Benefits (fracture reduction) far outweigh risks for most high-risk patients. Shared decision-making essential.

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Risk	Details
Esophageal Injury	Ulceration, stricture, perforation. Prevention: Take with full glass water, stay upright ≥30 min, do not lie down.
Osteonecrosis of Jaw (ONJ)	Exposed necrotic bone >8 wks. Risk: dental surgery, poor hygiene, steroids, chemo, IV bisphosphonates (higher). Incidence: ~0.01–0.1% (oral).
Atypical Femoral Fracture (AFF)	Subtrochanteric/diaphyseal, transverse, bilateral prodrome. Associated with long-term use (>3–5 yrs). Incidence: ~3–5/10,000 pt-yrs.
Hypocalcemia	Ensure adequate Ca²⁺/Vit D intake. Check levels if malabsorption, renal disease.
Renal Impairment	Contraindicated if CrCl <35 mL/min (accumulation).
Drug Interactions	Ca²⁺, antacids, Fe, Mg supplements → separate by ≥30 min. PPIs may reduce absorption.