PEARL: Bisphosphonates are not recommended for patients with severe renal impairment!

FDA has contraindications and warning on renal impairment for bisphosphonates:

• Alendronate not recommended for patients with creatinine clearance <35 ml/min (link to FDA package insert)
• Ibandronate not recommended for patients with creatinine clearance <30 ml/min (link to FDA package insert)
• Risedronate not recommended for patients with creatinine clearance <30 ml/min (link to FDA package insert)
• Zoledronic acid has limited pharmacokinetic data in patients with creatinine clearance < 30 ml/min (link to FDA package insert)

These contraindications and warnings come from cases of renal impairment and acute renal failure while on bisphosphonate therapy. For further reading, see Renal safety in patients treated with bisphosphonates for osteoporosis: A review