What are the possible adverse effects of bisphosphonate therapy for bone health management of breast cancer and how are they managed??

Updated: Nov 06, 2019
  • Author: Winston W Tan, MD, FACP; Chief Editor: Marie Catherine Lee, MD, FACS  more...
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In general, adverse effects for bisphosphonates include bone, joint, or muscle pain, as well as nausea, vomiting, and diarrhea. Oral bisphosphonates pose a higher risk of heartburn and esophagitis than their intravenously administered counterparts.

Osteonecrosis of the jaw (ONJ), a particularly difficult and unpleasant adverse effect, has an incidence of 3% in bisphosphonate-treated breast cancer patients. Patients with underlying oral pathology (eg, previous radiation to the area, need for invasive oral procedures, poor dental hygiene) are at a higher risk of developing ONJ.

International guidelines on ONJ include the following recommendations on reducing risk of ONJ and managing cases of ONJ [23] :

  • Before being started on bone-modifying agents (BMAs), patients with cancer should undergo an oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible). Based on the assessment, the dentist and oncologist should develop and implement a dental care plan to ensure that the patient undergoes any medically necessary dental procedures before starting the BMA. Once BMA therapy has been initiated, the dentist should perform follow-up on a routine schedule (eg, every 6 months).

  • Members of the multidisciplinary team should address modifiable risk factors for ONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use.

  • Elective dentoalveolar surgical procedures (eg, nonmedically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in the prevention and treatment of ONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team.

  • If dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (eg, every 6 to 8 weeks) until full mucosal coverage of the surgical site has occurred. Communication with the oncologist regarding the status of healing is encouraged, particularly when considering future use of BMAs.

  • For patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA before dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.

  • Initial treatment of ONJ consists of conservative measures such as antimicrobial mouth rinses, antibiotics if clinically indicated, effective oral hygiene, and conservative surgical interventions (eg, removal of a superficial bone spicule).

  • If ONJ results in persistent symptoms or affects function despite initial conservative treatment, aggressive surgical interventions (eg, mucosal flap elevation, block resection of necrotic bone, or soft tissue closure) may be used. Aggressive surgical intervention is not recommended for asymptomatic bone exposure. Before aggressive surgical intervention, the multidisciplinary care team and patient should thoroughly discuss the risks and benefits of the proposed intervention.

  • For patients who are diagnosed with ONJ while being treated with BMAs, there is insufficient evidence to support or refute the discontinuation of the BMAs. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.

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