Bisphosphonates

Bisphosphonates are a group of drugs that can be used by men with prostate cancer that has spread to the bones (advanced prostate cancer). Prostate cancer that has spread to the bones is not the same as bone cancer, which starts in the bones.

Each hospital will do things slightly differently so use this information as a general guide and ask your specialist team for more details about the care you will receive. You can also call our confidential Helpline.

Updated February 2011
To be reviewed February 2013

Why might I need to take bisphosphonates?+

You may be offered bisphosphonates if your prostate cancer has spread to the bones (advanced prostate cancer) and is no longer responding to hormone therapy.1, 2 If your prostate cancer has spread to the bones, the cancer may cause damage to the bones. This may result in bone pain. Bisphosphonates are used help to relieve bone pain. They do not treat the cancer itself.

Bisphosphonates can also help prevent a condition called hypercalcaemia where the amount of calcium in your blood increases. Calcium is usually stored in the bones but in some cancers too much may be released into the blood. This is rare in men with prostate cancer. Symptoms of hypercalcaemia include thirst, drowsiness and sickness.

If your cancer has spread to your bones, you may be at a higher risk of broken bones (fractures) because the cancer can weaken the bones. Bisphosphonates may help to prevent and slow down the rate of damage to the bone.3 However, the National Institute for Health and Clinical Excellence (NICE) guidelines do not recommend that bisphosphonates are used in this way. This is because there is not enough evidence to show that they are effective in helping to prevent broken bones in men with prostate cancer.4

Bisphosphonates for relieving bone pain are not widely available in Scotland, although they may be available in some areas. If you live in Scotland, speak to your specialist team about your t options for treating bone pain.

There are trials looking at using bisphosphonates in men with prostate cancer. You can read more about taking part in a clinical trial on our clinical trials page. You can find details of trials for prostate cancer treatments at CancerHelp.

Your specialist team can give you more information about how bisphosphonates may benefit you.

How do bisphosphonates work?+

Healthy bones continuously break down and rebuild. This is how our bones stay strong. When prostate cancer spreads to the bone it can cause the bone tissue to break down too fast. Your bones cannot replace the bone tissue at the same rate and your bones may become weak, more likely to break and you may get bone pain. Bisphosphonates bind to damaged areas of the bone and slow down the breakdown of bone tissue.5 This helps to strengthen the bone and relieve pain.

Other treatments that can help with bone problems include:

  • Palliative radiotherapy - this shrinks the cancer cells and slows the growth of cancer, relieving pain and helping to strengthen your bones.
  • Surgery to stabilise or fix the bone
  • Pain-relieving drugs, which can be used alone or in combination with other treatments.
  • Drugs to treat the cancer itself, such as hormone therapy or chemotherapy. These treatments will treat the cancer wherever it is in the body, including the bones.

When deciding on a treatment, you will need to think about how effective the treatment is likely to be and the risk of side effects. Talk to your specialist team about what may be right for you. You may be able to have bisphosphonates if other treatments have not been effective. You may also be given bisphosphonates alongside other treatments. You can read more about these treatments on our treatment choices pages.

What are the advantages and disadvantages?+

Advantages:

  • Helping to relieve bone pain
  • Controlling and reducing high levels of calcium in the blood
  • Many men may have a better quality of life due to less pain and being able to move around more easily
  • Possibly reducing the risk of broken bones

Disadvantages:

  • Side effects such as feeling sick, tiredness and flu-like symptoms
  • Travelling to the hospital every three or four weeks for treatment, if you are having an infusion into a vein
What does treatment involve?+

There are several bisphosphonate drugs available. Zoledronic acid (Zometa) is used to relieve bone pain in men with prostate cancer. Other bisphosphonate drugs include pamidronate (Aredia) or clodronate (Bonefos, Loron). You may receive other bisphosphonates if you have high calcium levels in your blood (hypercalcaemia) or if you have had bad side effects from zoledronic acid. Your doctor will explain which drug they are recommending for you and why.

Before treatment
Before you start bisphosphonate treatment, it is important to tell your doctor if you have ever had any problems with your liver, kidneys, heart, teeth or jaw. You should have a dental check up before your start your treatment. This is to reduce the risk of developing a condition called osteonecrosis of the jaw.6

If you are having an infusion (see below), drink plenty of water before each treatment to stop you becoming dehydrated. Your doctor can give you advice on this. You will have a blood test before each infusion to check that your kidneys are working properly.7

Your doctor or nurse will also do regular blood tests to check the amount of calcium, magnesium and phosphate in your blood. These minerals are used by the body to build new bone. If the tests show that your levels are low, you may need to take supplements such as calcium and vitamin D.7 Your doctor or nurse will give you more information about supplements.

Treatment
Zoledronic acid and pamidronate are usually given as an infusion into a vein every three to four weeks. An infusion involves passing a fluid containing the drug through a fine tube called a cannula (drip) into a vein in your arm. Treatment takes about 15 minutes. You will need to go to the hospital for each treatment.

Other bisphosphonates, such as clodronate, may be given as tablets, so you will not have to make regular trips to the hospital. If you are taking tablets, you should take them on an empty stomach with plenty of water, and wait at least an hour before eating. This is to allow the drug to be properly absorbed by the body. Read the information leaflet that comes with your medication for more information about this.

What happens afterwards?
If you are taking bisphosphonates to help relieve pain, you can take them for as long as they are working for you. There may be some side effects from these drugs but your specialist team will discuss these with you before you begin your treatment.

What are the side effects?+

Side effects will vary from person to person. They will also depend on which drug you are taking. The most common side effects are listed below.7, 8 You may not get all or any of these. The side effects of bisphosphonates are usually mild. Your cancer may also cause symptoms even if you are not taking bisphosphonates.

Common side effects may include:

  • An increase in bone pain when you first take the drugs
  • Flu-like symptoms such as joint, bone and muscle ache, headache, tiredness and raised temperature. These symptoms are generally mild and usually last up to 24 hours after treatment. Tell your doctor if you have any of these symptoms. Taking paracetamol can help to relieve them.
  • Feeling or being sick (nausea and vomiting) or loss of appetite
  • A drop in the level of red blood cells (anaemia) - this may make you look pale and feel weak
  • Rash and itching
  • Eye irritation (conjunctivitis)
  • Changes in how well your kidneys work. These changes are not usually serious, and are not permanent.9 Your specialist team may do regular blood tests to check your kidneys.

Many of these side effects only last a few days. Your doctor or specialist nurse will be able to give you medicine to relieve the symptoms if necessary. Pain-relieving drugs can help with bone pain until it calms down.

Less common side effects include:

  • Lowered levels of calcium and other minerals in your body such as potassium and magnesium. Your doctor will do regular blood tests to check these.10 You may need to take calcium and vitamin D supplements.
  • Irritation of the oesophagus (the tube which food passes down when you swallow) causing inflammation and ulcers. Tell your specialist team if you have any problems swallowing, pain or heartburn.11
  • Risk of heart problems. One recent study has found that bisphosphonates may slightly increase the risk of heart problems including a fast and irregular heartbeat and stroke. However, more research is needed to show clearly whether this is a side effect of bisphosphonates.12

There is also a rare condition called osteonecrosis of the jaw that can develop if you take bisphosphonates. It is more common in men who receive bisphosphonates as an infusion than those who take them in a tablet. The healthy bone underneath the teeth dies because of a poor blood supply to this area. This seems to happen more commonly in people who have had a lot dental treatment. If possible you should not have any invasive dental work such as tooth extractions or jaw surgery if you are using these drugs. Having routine cleaning or fillings should not cause a problem. If you need any further dental work your specialist may need to stop the bisphosphonate treatment before this is done. Treatment can continue once the dental work is finished.

Tell your specialist team if you have any loose teeth, gum problems (pain, swelling, infections) and numbness or a heavy feeling in the jaw. Good oral hygiene is also important. Let your dentist know that you are receiving bisphosphonates. Your specialist may give you a letter for your dentist explaining your treatment. It may be a good idea to visit your dentist before starting bisphosphonate treatment to get any existing dental problems sorted out, and to have regular dental check ups during treatment.66

Reporting unusual side effects: The Yellow Card Scheme
If you think you are experiencing a side effect from your medication that is not mentioned in the information leaflet that comes with it, then you can report it using the Yellow Card Scheme. This is run by the Medicines and Healthcare products Regulatory Agency (MHRA). They will investigate and if they find a problem with a medication then the MHRA will take action to protect the public.

There are three ways you can report a side effect:

  • Use the online Yellow Card form
  • Ask your pharmacist for a Yellow Card form
  • Call the Yellow Card freephone on 0808 100 3352
Where can I get support?+

As well as getting medical help to treat your pain, most men find it helps to get some emotional support. Feeling more in control of your emotions can help you feel better.

Close friends and relatives often say that it can be difficult to watch a loved one in pain. They can feel helpless and have trouble coping so they may also need emotional and practical support.

If you are feeling low or anxious, it may be useful to talk to a counsellor. Counselling may help you cope if you are experiencing pain. You may be able to get a referral to a counsellor through your specialist team or GP.

You may find it helpful to speak to someone with personal experience of pain caused by prostate cancer. Our support volunteers are all personally affected by prostate cancer and are trained to listen and offer support over the telephone. There are also prostate cancer support groups throughout the country where you and your family can meet other people affected by prostate cancer.

You can also join our online community. This is for men with prostate cancer and their families to share experiences, information and support.

You may also find that it helps to talk to your specialist team or a specialist cancer nurse such as a Macmillan or Marie Curie nurse. Many specialist nurses have counselling training and can help you work through some of your concerns. They also know a lot about cancer pain and how to manage it. Specialist nurses can also offer emotional support for you and your family. They work very closely with the district nurses and your GP. You can ask your GP or specialist team to refer you to these nursing services.

Questions to ask your specialist team+
  • Would you recommend bisphosphonate treatment for me?
  • What are the main benefits of bisphosphonates?
  • What are the main side effects of bisphosphonates?
  • Who do I contact if I have side effects?
  • Are there any trials of bone drugs which I can take part in at my own hospital or somewhere else?
More information+

CancerHelp UK
Freephone: 0808 800 4040 9am-5pm, Mon-Fri
CancerHelp is the patient information website of Cancer Research UK and provides information about current clinical trials for cancer.

Carers UK
Helpline: 0808 808 7777 10-12am & 2-4pm, Wed and Thurs
Provides information and advice for carers including signposting to support groups.

Healthtalkonline
Watch, listen to or read personal experiences of men with prostate cancer and other medical conditions.

Macmillan Cancer Support
Freephone: 0808 808 00 00
Practical, emotional and financial support for people with cancer, family and friends. Information about cancer, its treatment and living with cancer.

Maggie's Cancer Caring Centres
General enquiries: 0300 123 1801
Cancer information and support centres located in several towns and cities around the UK. Provide information and support services for people affected by cancer.

Pain Concern
Helpline: 0844 499 4676 (Monday to Friday, 10am to 4pm)
Offers information and support for people with pain and those who care for them.

UK Prostate Link
This website guides you to reliable sources of prostate cancer information.

Reviewers+

Reviewed by:

  • Lawrence Drudge-Coates, Urological Oncology Clinical Nurse Specialist & Honorary Lecturer, King's College Hospital, London
  • Louisa Fleure, Prostate Cancer Nurse Specialist, Guy's Hospital, London
  • Rob Jones, Senior Lecturer and Honorary Consultant in Medical Oncology, CRUK Beatson Laboratories, Glasgow
  • Linda Welsh, Prostate Specialist Radiographer & Clinical Research Radiographer, Torbay Hospital, South Devon NHS Healthcare Trust
  • Prostate Cancer Voices
  • The Prostate Cancer Charity Support & Information Specialist Nurses

Written and edited by:
The Prostate Cancer Charity Information Team

References+

References to sources of information used to produce this page:

1 British Uro-oncology Group, British Association of Urological Surgeons, British Prostate Group. MDT (Multi-disciplinary Team) guidance for managing prostate cancer. 2nd Edition. 2009.
2 National Institute for Health and Clinical Excellence, Prostate Cancer: diagnosis and treatment (Full guidance). February 2008
3 Yuen KK, Shelley M, Sze WM, Wilt T, Mason MD. Bisphosphonates for advanced prostate cancer. Cochrane Database of Systematic Reviews 2006, Issue 4.
4 National Institute for Health and Clinical Excellence, Prostate Cancer: diagnosis and treatment (Full guidance). February 2008
5 Drudge-Coates L. Skeletal complications and the use of bisphosphonates in metastatic prostate cancer. International Journal of Palliative Nursing. 2006;12(10):462-469
6 Medicines and Healthcare products Regulatory Agency. Drug Safety Update. Volume 3, Issue 2, November 2009.
7 Electronic medicines compendium. Zometa 4mg/5ml concentrate for solution for infusion. At: http://www.medicines.org.uk/EMC/medicine/14062/SPC/Zometa+4mg+5ml+Concentrate+for+Solution+for+Infusion/ Accessed 12 January 2011.
8 Novartis Oncology. Zometa. Information for patients. August 2008.
9 Augier Buganda D, Bohn Sarmiento U, Cabrera Sua´ rez MA, Aguiar Morales J. Assessment of renal toxicity and osteonecrosis of the jaws in patients receiving zoledronic acid for bone metastasis. Annals of Oncology. 2007;18:556-560,
10 Electronic medicines compendium. Zometa 4mg/5ml concentrate for solution for infusion. At: http://www.medicines.org.uk/EMC/medicine/14062/SPC/Zometa+4mg+5ml+Concentrate+for+Solution+for+Infusion/. Accessed 8 February 2011.8
11 Electronic medicines compendium. Bondronat 50mg film-coated tablets. Available at: http://www.medicines.org.uk/EMC/medicine/13838/SPC/Bondronat+50mg+Film-coated+Tablets/#UNDESIRABLE_EFFECTS. Accessed 21 December 2010.
12 Wilkinson GS, Baillargeon J, Kuo Y-F, Freeman JL, Goodwin JS. Atrial Fibrillation and Stroke Associated With Intravenous Bisphosphonate Therapy in Older Patients With Cancer. Journal of Clinical Oncology. 2010;28(33):4898-905.