Pearl: Oral bisphosphonates can cause erosive esophagitis, worsen GERD, and have low rates of adherence compared to other first line therapies.

Oral bisphosphonates are associated with erosive esophagitis and may worsen GERD especially in those with poorly controlled symptoms or with dysphagia. 

• Taking oral bisphosphonates with recommended precautions improves tolerance.
• To reduce risk, instruct patients to “Take 30 minutes before first food/drink, take with glass of water, stay upright for 30 minutes after”

Oral bisphosphonates also require either daily, weekly, or monthly dosing and adherence rates for oral bisphosphonates are low.

• After 1-year, orals had adherence of 20-31%
• IV infusions (zoledronic acid; 90%) or less frequent injectables (denosumab every six months; 70%) are more favorable