Pharmaceutical management of bone catabolism: the bisphosphonates

Background: Conditions associated with catabolism of bone are common and progress sub-clinically with devastating skeletal consequences. Over the past two decades, bisphosphonates have become increasingly popular for the preventative management of the skeleton in these conditions. Methods: Recent literature pertaining to the mechanisms of action, clinical indications and complications of bisphosphonate therapy was retrieved using Google Scholar and Pubmed. Aims of study: To provide an overview of the mechanisms of action, indications, contraindications and complications of the bisphosphonates available for clinical use in South Africa. Results: Despite the availability of alternative management regimens, bisphosphonates remain the pharmaceuticals of choice for the management of hypercalcaemia and generalised catabolic skeletal disorders such as osteoporosis, skeletal metastatic disease, Paget’s disease of bone, glucocorticoid bone disease and osteogenesis imperfecta. Although adverse complications such as tachycardia, bowel and oesophageal irritation, pain, jawbone necrosis and atypical femur fractures are well documented, information remains limited on the long-term effects of bisphosphonate therapy on skeletal health. This manuscript provides an update on the mechanisms of action, principles applied to the selection of the most appropriate management regimen, monitoring of the response and complications of the bisphosphonates marketed in South Africa. Level of evidence: Level 5.