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Recommendations for use of Bisphosphonates

Clinical practice recommendations

The recommendations are based on the statements of evidence for use of bisphosphonates for advanced breast cancer.

Recommendations to individuals should be based on their circumstances, the absolute benefits and harms of treatment, and their personal preferences. These factors should be discussed with the woman.4

Clinicians should conduct a dental examination and be aware of baseline tests (biochemistry including creatinine, serum calcium and vitamin D) and contraindicationsa prior to prescribing bisphosphonates. Women taking bisphosphonates should be reviewed regularly and monitored for adverse events by clinicians familiar with bisphosphonates.


RECOMMENDATIONS
LEVEL OF EVIDENCE5 REFERENCE
In women with advanced breast cancer and clinically evident bone metastases
(who may or may not be having systemic therapy):

Bone health

Bisphosphonates should be considered to reduce:

  • risk of developing a skeletal event
  • risk of hypercalcaemia
  • rate (frequency) of skeletal events
I Cochrane2
Bisphosphonates should be considered to delay time to a skeletal event I Cochrane2

Bone pain
Bisphosphonates should be considered to reduce bone pain I Cochrane2

Type of bisphosphonate and mode of administration

The type of bisphosphonate and mode of administration should be tailored to the individual s situation with regard to disease, treatment and patient factors and individual patient benefit:

Disease

  • number and location of bone metastases
  • presence of bone pain
  • hypercalcaemia

Treatment

  • long-term effects of bisphosphonates
  • toxicities and their management
  • frequency and mode of administration of other anticancer therapies

Patient

  • patient performance status and overall prognosis
  • patient preference
  • renal function
  • accessibility of services

Schedule and duration of administration

Effective doses and schedule are:

  • Intravenous ibandronate: 6mg every 4 weeks
  • Intravenous pamidronate: 90mg every 3 4 weeks
  • Intravenous zoledronic acid: 4mg every 3 4 weeks
  • Oral clodronate: 1600mg daily
  • Oral ibandronate: 50mg daily
Pharmaceutical Benefits Scheme5
In the absence of unacceptable toxicities, bisphosphonate use beyond 2 3 years should be considered on a case by case basis by the clinician and patient after assessing clinical benefit and potential risks
Adverse eventsb

Dental assessment measures should be considered for patients:

  1. baseline mouth assessment with a dental visit to detect potential dental conditions and dental care if required
  2. ongoing good dental hygiene and dental checks
III-3 Ripamonti7
Women taking bisphosphonates should be routinely informed of the need for good dental health, and dental health and oral cavity should be monitored for osteonecrosis of the jaw Khosla8
Women taking zoledronic acid should be monitored for renal toxicity II Rosen9

a Contraindications and baseline tests for bisphosphonates mentioned in this guideline are available in the product information (PI) on the Pharmaceutical Benefits Scheme website at www.pbs.gov.au

b Precautionary information for bisphosphonates mentioned in this guideline is available in the product information (PI) on the Pharmaceutical Benefits Scheme website at www.pbs.gov.au

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