Treatment
Recommendation 4
➤ For patients who will receive adjuvant bisphosphonates (see
Recommendation 1), zoledronic acid at 4 mg intravenously over 15 min
(or longer) every six months for three to five years or clodronate orally
at 1600 mg/day for two to three years is recommended. Different
durations may be considered.
• More research is recommended comparing different bone-modifying agents, doses,
dosing intervals and durations.
Recommendation 5
➤ For purposes of adjuvant bisphosphonate use, the definition of
menopause should include both natural menopause (at least 12 months
of amenorrhea prior to initiation of chemotherapy or endocrine therapy)
and menopause induced by ovarian ablation or suppression (but not the
cessation of menses due to chemotherapy alone). In women age ≤60
years with a previous hysterectomy and ovaries left in place, luteinizing
hormone, follicle-stimulating hormone, and serum estradiol should be
in the postmenopausal range and measured prior to initiation of any
systemic therapy in order to receive adjuvant bisphosphonates.
Recommendation 6
➤ A dental assessment is recommended where feasible prior to
commencement of bisphosphonates, and any pending dental or oral
health problems should be dealt with prior to starting treatment
if possible. Patients should be informed of the risk of developing
osteonecrosis of the jaw (ONJ), especially with tooth extractions and
other invasive dental procedures. Patients should inform their dental
practitioner of their treatment. Patients with suspected ONJ should be
referred to a dental practitioner with expertise in treating this condition.
Recent guidelines or position papers by groups such as the International
Task Force on Osteonecrosis of the Jaw, the American Association of Oral
and Maxillofacial Surgeons and the American Dental Association should
be consulted.
• Patients should have serum calcium measured prior to starting treatment. Patients
receiving intravenous bisphosphonates (zoledronic acid) should be monitored for
renal function prior to starting this treatment, and for serum calcium and increase in
serum creatinine throughout the treatment period.
• Calcium and vitamin D supplementation is recommended unless otherwise
contraindicated. Oral bisphosphonates and calcium should not be taken
concurrently — several monographs suggest an interval of at least two hours to allow
maximum absorption.
• Symptoms such as ocular pain or loss of vision may be due to serious inflammatory
conditions such as uveitis or scleritis and should be promptly evaluated by an
ophthalmologist.
