Learning Outcomes
By the end of this section, you should be able to:
- 27.3.1 Identify the characteristics of calcium preparations, vitamin D, bisphosphonates, calcimimetics, and peptide hormone drugs used to treat hypoparathyroidism.
- 27.3.2 Explain the indications, actions, adverse reactions, contraindications, and interactions of calcium preparations, vitamin D, bisphosphonates, calcimimetics, and peptide hormone drugs used to treat hypoparathyroidism.
- 27.3.3 Describe nursing implications of calcium preparations, vitamin D, bisphosphonates, calcimimetics, and peptide hormone drugs used to treat hypoparathyroidism.
- 27.3.4 Explain the client education related to calcium preparations, vitamin D, bisphosphonates, calcimimetics, and peptide hormone drugs used to treat hypoparathyroidism.
This section of the chapter discusses drugs used to treat parathyroid dysfunction. These drugs are used when parathyroid functioning is decreased or when calcium needs to be replaced or decreased to maintain its expected functions within the body.
Calcium Preparations
Calcium is a mineral utilized by the body to promote bone health. It also plays a role in blood clotting, muscle contraction, regulating heart rhythm, nerve function, and cell communication. Vitamin D is needed for the body to be able to absorb calcium. The two are often prescribed together.
The recommended daily amount of calcium is 1000–2000 mg for adults. Calcium can be found in many foods including dairy products such as milk, yogurt, and cheese; fish such as sardines and salmon; vegetables such as kale, broccoli, and cabbage; soy milk; almond milk; and tofu.
Special Considerations
Calcium and Race/Ethnicity, Age, and Socioeconomic Factors
In the United States, many Black and Asian people, as well as many adults experiencing poverty, aged 50 years and older, are less likely to get the recommended daily amounts of calcium (National Institutes of Health, 2023). As we age, our bodies absorb less calcium. For postmenopausal clients, a decrease in calcium absorption can lead to conditions such as osteoporosis.
This video on the role and importance of vitamin D (calcitriol) explains why vitamin D is vital for proper absorption and utilization of calcium.
Calcium
Some calcium supplements are available over the counter and are not regulated by the FDA. Clients should speak with their health care provider before starting any over-the-counter medication.
Calcium Acetate
Calcium acetate is used in the treatment of hypocalcemia and hyperphosphatemia but is contraindicated in clients with hypercalcemia. This phosphate binder, which comes in capsule form, reduces serum phosphate levels, thereby increasing serum calcium levels. Adverse effects include nausea, vomiting, constipation, gas, bloating, and headache.
Calcium Carbonate
Calcium carbonate is used in the treatment of hypocalcemia and can also be used as an antacid; it is contraindicated in clients with hypercalcemia. Like calcium acetate, this supplement reduces serum phosphate levels and results in increased serum calcium levels. This medication is available in a tablet, chewable tablet, capsule, and liquid. Adverse effects include upset stomach, vomiting, abdominal pain, bloating, constipation, dry mouth, loss of appetite, metallic taste, and increased urination.
Calcium Chloride
Calcium chloride is an injectable drug used in the treatment of hypocalcemia in those clients requiring a prompt increase in plasma calcium levels. Calcium chloride is contraindicated in cardiac resuscitation and for use in clients with hypercalcemia. It is administered via the intravenous route only. Adverse effects include vasodilation, decreased blood pressure, tingling sensation, and calcium taste (bitter and sour). Administration site reactions include local soft tissue inflammation, local necrosis, and extravasation.
Calcium Gluconate
Calcium gluconate is an injectable drug used in the treatment of acute symptomatic hypocalcemia. It increases serum ionized calcium levels. This medication is contraindicated in clients with hypercalcemia and in neonates (28 days old or younger) and should be used cautiously in clients with cardiac arrhythmias with concomitant cardiac glycoside use. Adverse effects include vasodilation, decreased blood pressure, cardiac arrhythmia, syncope, and cardiac arrest. Administration site reactions include local soft tissue inflammation, local necrosis, and extravasation.
Table 27.7 lists common calcium drugs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Calcium acetate (PhosLo, Eliphos) | Hyperphosphatemia (in chronic kidney disease): 1334 mg orally daily with each meal. |
| Calcium carbonate (Maalox, Tums) | Mild hypocalcemia: 500 mg orally daily. Adults and children over 12 years of age: Chew 2–4 tablets as symptoms occur. Maximum dose: Do not take more than 8 tablets in 24 hours. Do not use the maximum dose for more than 2 weeks. |
| Calcium chloride (CaCl, CaCl2) |
Individualized dosing by health care provider based on laboratory values. Usual adult dosage in hypocalcemic disorders: 200–1000 mg; slow intravenous push at intervals of 1–3 days depending on response of the client and/or serum ionized calcium determinations. |
| Calcium gluconate (Kalcinate) | Acute symptomatic hypocalcemia: Individualized dosing by health care provider based on laboratory values. Standard dosing starts at 1000–2000 mg intravenously initially; subsequent doses of 1000–2000 mg intravenously every 6 hours based on laboratory values (available in 100 mg/mL). |
Adverse Effects and Contraindications
Common adverse effects include kidney stones and gastrointestinal symptoms, such as constipation, bloating, abdominal discomfort, and flatulence. Drugs, such as tetracycline antibiotics, bisphosphates (e.g., alendronate), and thyroid hormone replacements, can interfere with calcium absorption so should be taken at separate times to minimize interactions. Hypercalcemia, another common adverse effect, leads to symptoms such as fatigue, confusion, constipation, increased thirst, and frequent urination.
Contraindications include hypersensitivity to the drug or any of its components. This medication is contraindicated for hypercalcemia because it will increase calcium levels in the blood and for hyperparathyroidism because increased calcium can worsen this condition. Kidney stones, as calcium preparation, may contribute to the formation of new kidney stones. Malabsorption syndrome, such as Celiac disease or Crohn’s disease, may occur because calcium may not be absorbed appropriately by the body with these conditions.
Table 27.8 is a drug prototype table for calcium carbonate. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Calcium preparation, antacid, and phosphate binder Mechanism of Action Acts in the small intestine by chelating with oxalate to prevent phosphate absorption, is absorbed in the small intestines to help circulate ionized calcium in the blood, inhibits pepsin and bile acid, increases gastric motility, and initiates peristalsis |
Drug Dosage Mild hypocalcemia: 500 mg orally daily. Adults and children over 12 years of age: Chew 2–4 tablets as symptoms occur. Maximum dose: Do not take more than 8 tablets in 24 hours. Do not use the maximum dose for more than 2 weeks. |
| Indications Hypocalcemia Hypothyroidism Hypoparathyroidism Osteoporosis Osteomalacia As a calcium supplement in postmenopausal clients and during pregnancy Therapeutic Effects Improves calcium levels within the body Reduces heartburn and gastroesophageal reflux disease Increases gut motility |
Drug Interactions Digoxin Phosphate supplements Sodium polystyrene sulfonate Food Interactions No significant interactions |
| Adverse Effects GI symptoms (upset stomach, vomiting, abdominal pain, bloating, constipation) Dry mouth Loss of appetite Metallic taste Increased urination |
Contraindications Hypersensitivity Hypercalcemia Caution: Monitor closely for kidney stones |
Vitamin D
Vitamin D is a fat-soluble vitamin that promotes calcium and phosphorous absorption in the intestines and helps to maintain adequate serum calcium and phosphate levels within the body. Vitamin D has other roles in the body—it reduces inflammation, and it stimulates insulin production in the modulation of cell function, neuromuscular and immune system function, and in glucose metabolism (Chauhan et al., 2022).
Vitamin D has two forms, vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Both forms are well absorbed by the gastrointestinal tract. The recommended daily allowance (RDA) of vitamin D for adults is 600–800 IU; however, replacement regimens for those with low vitamin D levels vary from the RDA.
Few foods naturally contain vitamin D. Those that do include trout, salmon, tuna, fish liver oils, beef liver, some mushrooms, and egg yolks. Some dairy products such as milk and cheeses are fortified with vitamin D. Sunlight is required for vitamin D synthesis; however, the FDA recommends sun protection such as sunscreen and limiting exposure to high sun times of day to prevent sun exposure complications such as skin cancer.
Ergocalciferol
Ergocalciferol is a synthetic calcium regulator. It mobilizes calcium and phosphate from bone and increases reabsorption of calcium and phosphate by the renal tubules, thereby increasing serum calcium and phosphate levels. This supplement is indicated in the treatment of hypoparathyroidism and in those with hypophosphatemia. It is frequently used off-label for vitamin D deficiency. It is contraindicated in clients with hypercalcemia, malabsorption syndrome, and hypervitaminosis D as well as clients with abnormal sensitivity to the toxic effects of vitamin D.
Calcitriol
Calcitriol is a synthetic vitamin D analog that is active in the regulation and absorption of calcium from the gastrointestinal tract. Calcitriol is readily absorbed from the intestine with peak serum concentration within 3–6 hours. It is 99.9% bound to protein in the blood and easily distributed. Calcitriol is indicated in the management of hypocalcemia and hypoparathyroidism. It is contraindicated in clients with hypercalcemia or evidence of vitamin D toxicity.
Table 27.9 lists common vitamin D drugs and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Ergocalciferol (Drisdol) | Hypoparathyroidism: Adults: 50,000–200,000 units daily concomitantly with calcium lactate 4 g, 6 times daily. |
| Calcitriol (Rocaltrol) | Hypoparathyroidism: Adults: 0.25 mcg orally daily in the morning; dose may be increased by health care provider in 2–4 weeks based on lab values. Children (≥3 years of age): 0.25 mcg orally daily; maximum dose 0.50 mcg orally daily. |
Adverse Effects and Contraindications
Common adverse effects include constipation, dry mouth, bone pain, metallic taste, polyuria, pruritis, increased liver enzymes (AST), and elevated blood urea nitrogen (BUN) levels.
Contraindications include hypersensitivity to the drug or any of its components, malabsorption disorders (such as Celiac disease or Crohn’s disease), vitamin D toxicity (symptoms include recurrent vomiting, confusion, apathy, and dehydration), and hypercalcemia (symptoms include nausea and vomiting, abdominal pain, and weight loss).
Table 27.10 is a drug prototype table for the vitamin D drug calcitriol. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Vitamin D analog Mechanism of Action Acts on cells in the gastrointestinal tract to increase the production of calcium transport proteins (calbindin-D proteins), which results in increased uptake of calcium from the intestines into the body |
Drug Dosage Hypoparathyroidism: Adults: 0.25 mcg orally daily in the morning; dose may be increased by health care provider in 2–4 weeks based on lab values. Children (≥3 years of age): 0.25 mcg orally daily; maximum dose 0.50 mcg orally daily. |
| Indications Hypocalcemia Hypoparathyroidism Hemodialysis clients with hyperphosphatemia Therapeutic Effects Increases serum calcium levels |
Drug Interactions Cholestyramine Phenytoin Thiazides Ketoconazole Mineral oil Food Interactions No significant interactions |
| Adverse Effects Early reactions: Weakness Headache Somnolence Nausea/vomiting Dry mouth Constipation Bone pain Metallic taste Late reactions: Polyuria Polydipsia Anorexia/weight loss Nocturia Pancreatitis Photophobia Pruritus Hyperthermia Elevated BUN Elevated liver enzymes Hypertension Cardiac arrhythmias |
Contraindications Hypersensitivity Hypercalcemia Vitamin D toxicity Caution: Use cautiously in clients with renal and hepatic impairment |
Bisphosphonates
Bisphosphonates are pyrophosphate analogues. They are divided into two groups: nitrogen-containing bisphosphonates and non-nitrogen-containing bisphosphonates that are not approved by the FDA in the treatment of osteoporosis. The nitrogen-containing agents are used in the treatment of osteoporosis and other associated conditions where bones are thin, fragile, and at an increased risk for fracture. Bisphosphonates inhibit bone resorption by attaching to hydroxyapatite binding sites on the bone. As osteoclasts resorb bone, the bisphosphonate embedded in the bone is released and impairs the osteoclast’s ability to continue bone resorption, thereby improving bone density (Ganesan at el., 2022).
Alendronate
Alendronate is a nitrogen-containing bisphosphonate that inhibits bone resorption and improves bone density. It is used in prevention and treatment of osteoporosis and to increase bone mass in male and female clients. This medication should be taken with 6–8 ounces of water, and the client should sit/stand for at least 30 minutes after administration to prevent esophageal irritation. Alendronate is contraindicated with esophageal abnormalities, the inability to stand/sit upright for 30 minutes, hypocalcemia, and hypersensitivity. Adverse effects include abdominal pain, acid regurgitation, constipation, diarrhea, dyspepsia, musculoskeletal pain, and nausea.
Ibandronate
Ibandronate is a potent nitrogen-containing bisphosphonate that is indicated for the treatment and prevention of postmenopausal osteoporosis and is available in tablet and injectable formulation. Oral dosing of ibandronate should be on an empty stomach with 6–8 ounces of water. The client should sit or stand for at least 60 minutes after administration to enhance absorption and prevent esophageal inflammation. This medication is contraindicated in clients with hypocalcemia, hypersensitivity, pregnancy, and abnormalities of the esophagus that delay emptying and those with the inability to sit/stand for at least 60 minutes after taking this drug. Adverse effects include back pain, dyspepsia, pain in extremities, diarrhea, headache, and myalgia.
Risedronate
Risedronate is also a nitrogen-containing bisphosphonate that is indicated in the treatment of postmenopausal osteoporosis. It is available as a delayed-release and immediate-release tablet and should be taken in the morning immediately following breakfast. The client should be able to sit/stand for at least 30 minutes following administration to facilitate delivery to the stomach and to avoid esophageal irritation. The delayed-release tablet should not be chewed, crushed, or cut. Risedronate is contraindicated in clients with hypocalcemia, with abnormalities of the esophagus that delay emptying, who are unable to sit/stand for at least 30 minutes after taking this drug, with hypersensitivity, and who are pregnant. Adverse effects include abdominal pain, constipation/diarrhea, nausea/vomiting, bronchitis, arthralgia, back pain, musculoskeletal pain, pain in the extremities, myalgia, dizziness, and headache.
Table 27.11 lists common bisphosphonate drugs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Alendronate (Fosamax) |
Treatment of osteoporosis: Daily dosing: 5–10 mg orally in the morning. Weekly dosing: 70 mg orally in the morning. |
| Ibandronate (Boniva) |
Treatment of osteoporosis: 150 mg orally once monthly or 3 mg intravenously 3 times a month. |
| Risedronate sodium (Actonel) | Treatment of osteoporosis: Immediate-release tablet: 5 mg orally once daily or 35 mg orally once weekly or 150 mg orally once monthly. Delayed-release tablet: 35 mg orally once weekly in the morning. |
Adverse Effects and Contraindications
Adverse effects of bisphosphonates drug class include gastrointestinal symptoms (such as abdominal pain, dyspepsia, nausea, vomiting, and diarrhea), esophageal irritation (leading to heartburn and difficulty swallowing), musculoskeletal pain, osteonecrosis of the jaw (death of bone tissue in the jaw leading to pain, swelling, infection, and exposed bone in severe cases), and atypical fractures.
Contraindications include hypersensitivity to the drugs or any of their components as well as severe renal impairment because these drugs are primarily excreted through the kidneys and use of these drugs can further impair kidney function. This class of drugs is also contraindicated in clients who have an inability to sit upright or stand for at least 30–60 minutes after taking the medication.
Table 27.12 is a drug prototype table for the bisphosphonate drug alendronate. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Bisphosphonate—nitrogen-containing Mechanism of Action Inhibits bone resorption to mineral surfaces and subsequent internalization by bone-resorbing osteoclasts where they interfere with biochemical processes and therefore improve bone density |
Drug Dosage Treatment of osteoporosis: Daily dosing: 5–10 mg orally in the morning. Weekly dosing: 70 mg orally in the morning. |
| Indications Osteoporosis in postmenopausal clients Paget’s disease Glucocorticoid-induced osteoporosis Therapeutic Effects Increases bone mass |
Drug Interactions Calcium supplements Antacids Aspirin Nonsteroidal anti-inflammatories (NSAIDs) Food Interactions No significant interactions |
| Adverse Effects Abdominal pain Acid regurgitation Constipation/diarrhea Dyspepsia Nausea Musculoskeletal pain |
Contraindications Hypersensitivity Hypocalcemia Abnormalities of the esophagus that delay emptying Inability to sit/stand upright for at least 30 minutes Pregnancy |
Calcimimetics
Calcimimetics are drugs that mimic the actions of calcium by allosteric activation of the calcium-sensing receptor (CaSR) in the parathyroid glands or other tissues. These drugs lower the activation of extracellular calcium ions and decrease PTH release, thus reducing the amount of calcium in the blood. Calcimimetics are used in the treatment of hyperparathyroidism and in clients who have hypercalcemia.
Cinacalcet
Cinacalcet is a positive modulator of the CaSR agonist and is indicated in the treatment of primary and secondary hyperparathyroidism and in the treatment of hypercalcemia. This medication should be taken with meals, and the tablet should not be chewed, crushed, or divided. Nurses should use cinacalcet cautiously in clients with upper gastrointestinal bleeding, those with hypotension and/or heart failure, and those with bone disease. Adverse effects include nausea and vomiting.
Adverse Effects and Contraindications
Adverse effects of calcimimetics include gastrointestinal symptoms such as nausea, vomiting, and abdominal pain; hypocalcemia where symptoms include muscle cramps, tingling, numbness in the fingers or lips, and seizures; hypophosphatemia where symptoms include muscle weakness, bone pain, and impaired energy metabolism; and adynamic bone disease, which is characterized by low bone turnover and increased risk of fractures.
Contraindications include hypersensitivity to the drug or any of its components and in those clients with hypocalcemia because this can cause further decrease in calcium levels and death. Calcimimetics should be used cautiously in clients with severe liver impairment because they are primarily metabolized by the liver and can further impair its function.
Table 27.13 is a drug prototype table for the calcimimetics drug cinacalcet. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Calcimimetic Mechanism of Action Amplifies the calcium-sensing receptor (CaSR) in the parathyroid gland, thereby suppressing PTH levels and in turn reducing blood calcium levels |
Drug Dosage Secondary hyperparathyroidism in clients with chronic kidney disease on dialysis: Recommended starting dose is 30 mg orally once daily. Serum calcium and serum phosphate levels should be measured within 1 week, and intact PTH (iPTH) should be measured 1–4 weeks after initiation. Dose adjustment should be titrated every 2–4 weeks through sequential dosing of 30, 60, 90, 120, and 180 mg orally once daily to target iPTH levels of 150–300 pg/mL. |
| Indications Primary and secondary hyperparathyroidism For the treatment of hypercalcemia in adults with parathyroid carcinoma Therapeutic Effects Reduces calcium levels in the blood |
Drug Interactions CYP3A4 (such as ketoconazole, itraconazole) CYP2D6 (such as desipramine, metoprolol, and carvedilol) Food Interactions No significant interactions |
| Adverse Effects Nausea/vomiting Abdominal pain Muscle cramps Bone pain Increased risk for fractures |
Contraindications Hypersensitivity Hypocalcemia Caution: Use cautiously in clients with severe liver impairment as cinacalcet is primary metabolized by the liver and can further impair its function |
Peptide Hormones
Peptide hormones are synthetic analog hormones used in the treatment of various disease processes. For this chapter, calcitonin salmon will be covered under this drug classification. This type of peptide hormone inhibits osteoclasts and increases renal excretion of calcium, thereby decreasing serum calcium levels. In the renal tubules, it reduces serum calcium and phosphate by promoting diuresis and decreasing reabsorption. In bone, this peptide hormone causes osteoclasts to contract, which reduces their motility and ability to resorb bone. For these reasons, this medication is used to treat postmenopausal osteoporosis, Paget’s disease of bone, and emergent hypercalcemia (Wang et al., 2022).
Calcitonin Salmon
Calcitonin salmon is a synthetic peptide hormone that is used in the treatment of hypercalcemia, postmenopausal osteoporosis when alternative therapies are not suitable, and symptomatic Paget’s disease. Calcitonin salmon is available as an injectable and nasal spray and is contraindicated in clients with hypersensitivity. Adverse effects of nasal administration include nasal reactions such as dryness and irritation, nausea with or without vomiting, injection site inflammation, and flushing of face or hands.
For preparation and administration of injectable calcitonin salmon, the client should visually inspect the injection vials to ensure the solution is clear and colorless. If the solution is not clear and colorless or contains any particles or if the vial is damaged, the client should discard the solution. If the volume of the drug exceeds 2 mL, intramuscular injection is preferable. The client should be instructed on how to use the sterile injection technique and to dispose of needles properly (DailyMed, Calcitonin Salmon Injection, 2023).
Adverse Effects and Contraindications
Adverse effects of peptide hormones include nasal dryness and irritation, nausea with or without vomiting, injection site inflammation, and flushing of hands or face.
Contraindications for peptide hormones include hypersensitivity to the drug or any of its components.
Table 27.14 is a drug prototype table for the peptide hormone drug calcitonin salmon. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Peptide hormone Mechanism of Action Inhibits osteoclasts, the cells that breakdown existing bone, thereby decreasing the rate of bone breakdown |
Drug Dosage Hypercalcemia: Recommended starting dose: 4 USP units/kg body weight every 12 hours by subcutaneous or intramuscular injection. If response is not satisfactory after 1–2 days, the dose may be increased to 8 USP units/kg every 12 hours. If the response remains unsatisfactory after 2 more days, the dose may be further increased to a maximum of 8 USP units/kg every 6 hours. Postmenopausal osteoporosis: In clients more than 5 years postmenopause: 100 USP units (0.5 mL) daily administered subcutaneously or intramuscularly. Nasal spray is one spray (200 USP calcitonin salmon units) daily administered intranasally, alternating nostrils daily. Paget’s disease: 100 USP units (0.5 mL) daily administered subcutaneously or intramuscularly. |
| Indications Hypercalcemia Postmenopausal osteoporosis Paget’s disease of the bone Therapeutic Effects Decreases the rate of bone breakdown |
Drug Interactions No signification interactions Food Interactions No significant interactions |
| Adverse Effects Nasal dryness and irritation Nausea with or without vomiting Injection site reaction/inflammation Flushing of face and hands |
Contraindications Hypersensitivity Caution: Use cautiously in clients who are taking lithium, because concomitant use of calcitonin salmon and lithium may lead to a reduction in plasma lithium concentration due to increased urinary clearance of lithium |
Nursing Implications
The nurse should do the following for clients who are taking calcium preparations, vitamin D, bisphosphonates, calcimimetics, and peptide hormones:
- Monitor calcium, vitamin D, phosphate, PTH, and thyroid hormones closely and report abnormalities to the health care provider.
- Ensure the client is able to sit/stand for 30–60 minutes after the administration of bisphosphonates.
- Educate the client taking calcium preparations, vitamin D, and bisphosphonates to eat foods high in calcium and vitamin D such as spinach, kale, soybeans, salmon, sardines, and fortified dairy products.
- Provide client teaching regarding the drug and when to call the health care provider. See below for additional client teaching guidelines.
Client Teaching Guidelines
The client taking a calcium preparation, vitamin D, bisphosphonate, calcimimetic, or peptide hormone should:
- Take the drug exactly as prescribed by the health care provider.
- Report gastrointestinal disturbance, muscle pain, muscle spasms, bone pain, fatigue, or rash to the health care provider because these may be symptoms of a severe reaction.
- Adhere to proper diet involving calcium and vitamin D products as instructed by the health care provider.
- Notify the health care provider if they are pregnant or plan to become pregnant or if they are breastfeeding.
- Store out of reach children and away from heat, moisture, and light.
The client taking a calcium preparation, vitamin D, bisphosphonate, calcimimetic, or peptide hormone should not:
- Take over-the-counter medications or herbal supplements without consulting with the health care provider.
- Lay in a supine position for 30–60 minutes after taking a bisphosphonate.
FDA Black Box Warning
Bisphosphonates
Jaw necrosis and subtrochanteric and diaphyseal femur fractures have been reported in clients treated with bisphosphonates.