Bisphosphonates in patients with moderate renal impairment

Can bisphosphonates be used in patients with moderate renal impairment? What are the potential adverse effects of these drugs? Is denosumab a better choice in such patients?

Alexandra Papaioannou, MD: Generally, in those with renal impairment who have creatinine clearance <30 mL/min we recommended to avoid bisphosphonates, particularly the IV bisphosphonates. In somebody with creatinine clearance between 15 to 30 mL/min you can consider something like denosumab, but it is really important to make sure that their vitamin D and calcium levels are adequate, because there is a higher risk of hypocalcemia in that group.