Rationalising bisphosphonates and denosumab used for cancer in palliative care

Follow the principles of medication rationalisation when rationalising bisphosphonates and denosumab in palliative care.

High-dose bisphosphate or denosumab is administered parenterally at regular intervals to patients with some cancers to promote bone health (ie reduce bone loss, metastases and skeletal-related complications). Current recommendations are to continue indefinitely in patients not experiencing adverse effects. However, adverse events, although rare, are serious and significantly decrease quality of life. The incidence of jaw osteonecrosis increases with dose and duration of therapy. Since bisphosphonates are retained in the bone for more than one year, these drugs can be stopped in the last months of life. In consultation with the patient’s oncologist, consider stopping when chemotherapy is ceased.

For advice on bisphosphonate or denosumab use for managing bone pain associated with cancer, see Managing bone pain associated with cancer in palliative care.

For advice on starting bisphosphonate in hypercalcaemia associated with cancer, see Hypercalcaemia associated with cancer.