Note: Etidronate 200 mg and 400 mg tablets have been discontinued in the US for more than 1 year.
Patients should receive supplemental calcium and vitamin D if dietary intake is inadequate.
Paget disease: Oral:
Initial: 5 mg/kg/day (not to exceed 6 months) is recommended as initial therapy; if higher doses are needed, may give 5 to 10 mg/kg/day (not to exceed 6 months) or 11 to 20 mg/kg/day (not to exceed 3 months). Doses >10 mg/kg/day should be used only when lower doses are ineffective or there is a need to suppress rapid bone turnover (ie, potential for irreversible neurologic damage) or reduce elevated cardiac output. Doses >20 mg/kg/day are not recommended.
Re-treatment: Initiate only after etidronate-free period ≥90 days. Monitor patients every 3 to 6 months. Re-treatment regimens are the same as for initial treatment. In cases where the original dose is not adequate, consider increasing the dose within the recommended guidelines.
Heterotopic ossification: Oral:
Caused by spinal cord injury: 20 mg/kg/day for 2 weeks, then 10 mg/kg/day for 10 weeks; total treatment period: 12 weeks
Complicating total hip replacement: 20 mg/kg/day for 1 month preoperatively then 20 mg/kg/day for 3 months postoperatively; total treatment period is 4 months
Re-treatment: Has not been studied.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Manufacturer’s labeling recommends decreasing the dose when GFR is reduced; however, no specific dosage adjustments are provided. Use with caution and monitor closely; etidronate is eliminated intact via the kidneys.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Etidronate (United States: Not available): Pediatric drug information")
Note: Etidronate 200 mg and 400 mg tablets have been discontinued in the US for more than 1 year.
Heterotopic ossification, traumatic brain injury: Limited data available: Children and Adolescents: Oral: Initial: 20 mg/kg/dose once daily for 2 to 4 weeks, then decrease to 10 mg/kg/dose once daily for 12 weeks to 1 year (Hurvitz 1992).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Manufacturer's labeling recommends decreasing the dose when GFR is reduced in adults; however, no specific dosage adjustments are provided. Use with caution and monitor closely; etidronate is eliminated intact via the kidneys.
There are no dosage adjustments provided in manufacturer's labeling.
Refer to adult dosing. Use with caution and monitor closely.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Tablet, Oral, as disodium:
Generic: 200 mg [DSC], 400 mg [DSC]
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Tablet, Oral, as disodium:
Generic: 200 mg, 400 mg [DSC]
Etidronate 200 mg and 400 mg tablets have been discontinued in the US for more than 1 year.
Oral: Administer tablet on an empty stomach with a full glass of plain water (6 to 8 oz) 2 hours before food. Patients should be instructed to stay upright (not to lie down) after taking the medication. If gastrointestinal discomfort occurs, the dose may be divided.
Oral: Administer on an empty stomach with a full glass of plain water (6 to 8 oz), 2 hours before meals. Patients should be instructed to stay upright (not to lie down) after taking the medication. Dose should be taken once daily, however, if GI upset occurs, doses can be divided.
Heterotopic ossification: Prevention and treatment of heterotopic ossification due to spinal cord injury or after total hip replacement
Paget disease: Symptomatic treatment of Paget disease of bone
Note: Not generally a recommended treatment option; guidelines recommend the use of more potent bisphosphonate therapy (eg, zoledronic acid) (Endocrine Society [Singer 2014]; Ralston 2019).
Etidronate may be confused with etomidate
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Gastrointestinal: Diarrhea (≤30%; dose dependent), nausea (≤30%; dose dependent)
Neuromuscular & skeletal: Ostealgia (10% to 20%; dose dependent)
Postmarketing and/or case reports: Agranulocytosis, alopecia, amnesia, angioedema, arthralgia, arthritis, bone fracture, confusion, depression, erythema multiforme, esophagitis, exacerbation of asthma, exacerbation of peptic ulcer, folliculitis, gastritis, glossitis, glossopyrosis, hallucination, headache, hypersensitivity reaction, leg cramps, leukemia, leukopenia, maculopapular rash, osteomalacia, osteonecrosis of the jaw, pancytopenia, paresthesia, pruritus, skin rash (macular), Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Hypersensitivity to bisphosphonates or any component of the formulation; overt osteomalacia; patients with abnormalities of the esophagus (eg, stricture, achalasia) which delay esophageal emptying
Concerns related to adverse effects:
• Bone/joint/muscle pain: Infrequently, severe (and occasionally debilitating) bone, joint, and/or muscle pain have been reported during bisphosphonate treatment. The onset of pain ranged from a single day to several months. Consider discontinuing therapy in patients who experience severe symptoms; symptoms usually resolve upon discontinuation. Some patients experienced recurrence when rechallenged with same drug or another bisphosphonate; avoid use in patients with a history of these symptoms in association with bisphosphonate therapy.
• Fracture risk: Do not exceed recommended dose or use continuously for >6 months in patients with Paget's disease; risk of osteomalacia or fractures may be increased. Long bones with predominantly lytic lesions may be prone to fracture, particularly in patients unresponsive to treatment.
• GI mucosa irritation: May cause irritation to upper GI mucosa. Esophagitis, dysphagia, esophageal ulcers, esophageal erosions, and esophageal stricture (rare) have been reported with oral bisphosphonates; risk increases in patients unable to comply with dosing instructions. Use with caution in patients with dysphagia, esophageal disease, gastritis, duodenitis, or ulcers (may worsen underlying condition). Discontinue use if new or worsening symptoms develop.
• Osteonecrosis of the jaw: Osteonecrosis of the jaw (ONJ), also referred to as medication-related osteonecrosis of the jaw (MRONJ), has been reported in patients receiving bisphosphonates; this has been observed primarily following dental procedures such as tooth extractions and in cancer patients receiving IV bisphosphonates, but has also occurred in patients with postmenopausal osteoporosis and other diagnoses receiving oral bisphosphonates. Risk factors for MRONJ include invasive dental procedures (eg, tooth extraction, dental implants, boney surgery), cancer diagnosis, concomitant chemotherapy, radiotherapy, or corticosteroids; anemia, coagulopathy, infection, ill-fitting dentures, or preexisting dental disease. According to a position paper by the American Association of Maxillofacial Surgeons (AAOMS), MRONJ has been associated with bisphosphonate and other antiresorptive agents (denosumab), and antiangiogenic agents (eg, bevacizumab, sunitinib) used for the treatment of osteoporosis or malignancy. The manufacturer’s labeling states that discontinuing bisphosphonates in patients requiring invasive dental procedures may reduce the risk of ONJ and clinical judgment should guide the decision. However, the AAOMS suggests there is currently no evidence that interrupting oral bisphosphonate therapy alters the risk of ONJ following tooth extraction, and that in patients receiving oral bisphosphonates for <4 years who have no clinical risk factors, no alternations or delay in any procedure common to oral/maxillofacial surgeons, periodontists, and other dental providers is necessary (special considerations apply to patients receiving dental implants). Conversely, in patients receiving oral bisphosphonates for >4 years or in patients receiving oral bisphosphonates for <4 years who have also taken corticosteroids or antiangiogenic medications concomitantly, the AAOMS recommends considering a 2-month drug free period prior to invasive dental procedures (recommendation based on a theoretical benefit). Patients developing ONJ during therapy should receive care by an oral surgeon (AAOMS [Ruggiero 2014]). According to the manufacturer, discontinuation of the bisphosphonate therapy should be considered (based on risk/benefit evaluation) in patients who develop ONJ.
Disease-related concerns:
• Bariatric surgery: Altered absorption and ulceration risk: Avoid oral bisphosphates after bariatric surgery; inadequate oral absorption and potential anastomotic ulceration may occur. If therapy is indicated, IV administered bisphosphonates are recommended.
• Enterocolitis: Use with caution in patients with enterocolitis; diarrhea has been reported at high doses and therapy may need to be withheld.
• Renal impairment: Use with caution in patients with renal impairment.
Other warnings/precautions:
• Bone mineralization: May retard mineralization of bone; treatment may need delayed or interrupted until callus is present.
• Calcium/vitamin D intake: Ensure adequate calcium and vitamin D intake.
Prolonged therapy may lead to rachitic syndrome; doses of ≥10 mg/kg/day for ~1 year have been associated with rachitic syndrome when etidronate was used to prevent heterotopic ossifications or soft tissue calcifications; radiologic changes and symptoms have been reversed upon discontinuation.
None known.
Aminoglycosides: May enhance the hypocalcemic effect of Bisphosphonate Derivatives. Risk C: Monitor therapy
Angiogenesis Inhibitors (Systemic): May enhance the adverse/toxic effect of Bisphosphonate Derivatives. Specifically, the risk for osteonecrosis of the jaw may be increased. Risk C: Monitor therapy
Deferasirox: Bisphosphonate Derivatives may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor therapy
Inhibitors of the Proton Pump (PPIs and PCABs): May diminish the therapeutic effect of Bisphosphonate Derivatives. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May enhance the adverse/toxic effect of Bisphosphonate Derivatives. Both an increased risk of gastrointestinal ulceration and an increased risk of nephrotoxicity are of concern. Risk C: Monitor therapy
Polyvalent Cation Containing Products: May decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral medications containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate. Risk D: Consider therapy modification
Food and/or supplements decrease the absorption and bioavailability of the drug. Management: Administer tablet on an empty stomach with a full glass of plain water or fruit juice (6 to 8 oz) 2 hours before food. Avoid administering foods/supplements with calcium, iron, or magnesium within 2 hours of drug. Do not take with mineral water or other beverages.
Bisphosphonates are incorporated into the bone matrix and gradually released over time. Because exposure prior to pregnancy may theoretically increase the risk of fetal harm, use in premenopausal females should be reserved for special circumstances when rapid bone loss is occurring (Bhalla 2010; Pereira 2012; Stathopoulos 2011).
It is not known if bisphosphonates cross the placenta, but based on their lower molecular weight, fetal exposure is expected (Djokanovic 2008; Stathopoulos 2011).
Information related to the use of etidronate in pregnancy is available from case reports and small retrospective studies (Agarwal 2020; Levy 2009; Sokal 2019; Vujasinovic-Stupar 2012).
Bisphosphonates are incorporated into the bone matrix and gradually released over time. The amount available in the systemic circulation varies by drug, dose, and duration of therapy. Theoretically, there may be a risk of fetal harm when pregnancy follows the completion of therapy (hypocalcemia, low birth weight, and decreased gestation have been observed in some case reports); however, available data have not shown that exposure to bisphosphonates during pregnancy significantly increases the risk of adverse fetal events (Djokanovic 2008; Green 2014; Levy 2009; Machairiotis 2019; Sokal 2019; Stathopoulos 2011). Exposed infants should be monitored for hypocalcemia after birth (Djokanovic 2008; Stathopoulos 2011).
It is not known if etidronate is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends a decision be made to discontinue breastfeeding or to discontinue the drug, taking considering the importance of treatment to the mother.
Ensure adequate calcium and vitamin D intake; women and men >50 years of age should consume 1,200 to 1,500 mg/day of elemental calcium and 800 to 1,000 units/day of vitamin D. Tablet should be taken with water or fruit juice on an empty stomach; avoid administering foods/supplements with calcium, iron, or magnesium within 2 hours of drug. Do not take with mineral water or with other beverages.
Paget disease: Serum total alkaline phosphatase at 6 to 12 weeks for initial response to treatment (when bone turnover will have shown a substantial decline) and potentially at 6 months (maximal suppression of high bone turnover); following treatment completion, monitor at ~6- to 12-month intervals (Endocrine Society [Singer 2014]); monitoring more specific biochemical markers of bone turnover (eg, serum P1NP, NTX, serum beta-CTx) is generally only warranted in patients with Paget disease who have abnormal liver or biliary tract function or when early assessment of response to treatment is needed (eg, spinal compression, very active disease) (Endocrine Society [Singer 2014]); pain (posttreatment pain may not strictly correlate with increased biochemical markers [Ralston 2019]); serum calcium and 25(OH)D.
Calcium (total): Adults: 9.0 to 11.0 mg/dL
Phosphorus: 2.5 to 4.5 mg/dL (0.81 to 1.45 mmol/L)
Vitamin D: There is no clear consensus on a reference range for total serum 25(OH)D concentrations or the validity of this level as it relates clinically to bone health. In addition, there is significant variability in the reporting of serum 25(OH)D levels as a result of different assay types in use; however, the following ranges have been suggested:
Adults (IOM 2011): Sufficient levels in practically all persons: ≥20 ng/mL (50 nmol/L); concern for risk of toxicity: >50 ng/mL (125 nmol/L)
Decreases bone resorption by inhibiting osteocytic osteolysis; decreases mineral release and matrix or collagen breakdown in bone
Onset of action: 1 to 3 months
Duration: Can persist for 12 months without continuous therapy
Absorption: ~3%
Metabolism: None
Half-life elimination: 1 to 6 hours
Excretion: Primarily urine (50% as unchanged drug); feces (as unabsorbed drug)
Tablets (Etidronate Disodium Oral)
200 mg (per each): $4.32
400 mg (per each): $8.64
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