Ibandronic Acid for Osteoporosis: The Monthly Tablet, the 3-Monthly Injection and Side Effects

Ibandronic acid (ibandronate, brand name Bonviva) is an osteoporosis medicine for women after the menopause, taken either as one 150mg tablet a month or as a 3mg injection into a vein every three months. It is a bisphosphonate, so it slows bone breakdown and lowers the risk of spine fractures. The tablet comes with one strict rule: take it on an empty stomach with plain water and stay upright with nothing else to eat or drink for a full hour.

What is ibandronic acid?

Ibandronic acid is a bisphosphonate, the same family as alendronic acid, risedronate and zoledronic acid, that protects bone by slowing the cells that break it down. It is licensed for the "treatment of osteoporosis in postmenopausal women at increased risk of fracture" emc, Bonviva 150mg SmPC. Its main selling point is convenience: one tablet a month, or four injections a year, instead of a weekly or daily routine.

The product information notes that it has been shown to reduce vertebral (spine) fractures, but that its effect on femoral neck (hip) fractures has not been established. For an overview of the whole drug class, see our guide to bisphosphonates for osteoporosis.

Who is ibandronic acid suitable for?

Ibandronic acid is usually considered for women after the menopause who have already tried another osteoporosis drug, or for whom other drugs are unsuitable. The Royal Osteoporosis Society (ROS) says it is "only licensed for use in women who have been through the menopause", although doctors sometimes offer it to men and occasionally to younger women Royal Osteoporosis Society.

The ROS says it may not suit you if you:

• have severe kidney problems
• have low blood calcium (hypocalcaemia). This needs correcting with calcium and vitamin D first
• are pregnant or breastfeeding
• are at high risk of hip fracture, because it is unclear whether it lowers hip fracture risk as much as other drugs.

The tablets may also be unsuitable if you cannot swallow tablets, have a gullet (oesophagus) problem such as Barrett's oesophagus, or cannot stay sitting or standing upright for at least an hour. The tablet product information lists inability to stay upright for 60 minutes, and gullet problems that slow emptying (such as a narrowing or achalasia), as reasons not to take it, and does not recommend it if your kidney function (creatinine clearance) is below 30 ml/min emc, Bonviva 150mg SmPC.

How do you take the monthly ibandronic acid tablet?

Take one 150mg tablet on the same date each month, as soon as you wake, after at least six hours without food, and swallow it whole with 180 to 240ml of plain water. Then follow the 60-minute rule emc, Bonviva 150mg SmPC:

1. Plain water only. The ROS specifies plain tap water, so no tea, coffee, juice or milk with the tablet.
2. Swallow it whole. Do not chew or suck it, because it can cause mouth ulcers.
3. Stay upright. Sit or stand, and do not lie down, for one hour.
4. Wait one hour before eating, drinking anything other than water, or taking other medicines or supplements, including calcium.

The ROS adds that some doctors suggest leaving up to four hours before a calcium supplement Royal Osteoporosis Society. A note on the calendar or a phone reminder helps, because a monthly dose is easy to forget.

What if you miss a monthly dose?

Take the missed tablet the morning after you remember, unless your next dose is due within 7 days. If it is due within 7 days, skip the missed tablet and take the next one on your usual date. Never take two tablets in the same week emc, Bonviva 150mg SmPC.

What is the 3-monthly ibandronic acid injection?

The injection is a 3mg dose given slowly into a vein over 15 to 30 seconds, once every three months, usually at a hospital. The product information sets the dose and the 15 to 30 second injection time emc, Bonviva 3mg injection SmPC. It can be an option for women who cannot follow the tablet routine or whose stomach cannot tolerate tablets.

There is no fasting rule: the ROS says you can eat and drink as normal on the day Royal Osteoporosis Society. The product information states that everyone having the injection must take supplemental calcium and vitamin D. It is not recommended if your serum creatinine is above 200 μmol/l. If an injection is missed, it should be given as soon as convenient, and the next ones are then scheduled every three months from that date.

What are the side effects of ibandronic acid?

The most frequently reported side effects are joint pain and flu-like symptoms, which usually come with the first dose, are mild to moderate and settle on their own. The product information describes the flu-like illness as muscle pain, fever, chills, tiredness, nausea, loss of appetite or bone pain emc, Bonviva 150mg SmPC.

The ROS gives these approximate figures Royal Osteoporosis Society:

• Tablets: inflamed gullet, sore throat, difficulty swallowing or heartburn in fewer than 1 in 10 people. Staying upright for the full hour helps.
• Injection: flu-like symptoms in up to 3 in 10 people after the first injection, falling to fewer than 1 in 10 with later injections.
• Both forms: bone, joint or muscle pain (fewer than 1 in 10) and eye inflammation (fewer than 1 in 100). See a doctor promptly for a painful red eye or blurred vision.
• Rare (fewer than 1 in 1,000): atypical thigh bone fracture after many years of treatment, and osteonecrosis of the jaw, usually after major dental work.

The product information also lists headache, dizziness, tiredness, back pain, muscle cramps, rash, nausea, indigestion and tummy pain among other reported effects. Tell your doctor about any new thigh, hip or groin pain, and tell your dentist you are taking a bisphosphonate. Keep up good oral hygiene and regular check-ups. Our article on alendronic acid side effects explains these shared rare risks in more depth.

How long do you take ibandronic acid for?

Plan on at least five years of tablets before a formal review. UK guidance from the National Osteoporosis Guideline Group (NOGG) makes a strong recommendation to plan oral bisphosphonates, including ibandronate, for at least five years, and longer for some higher-risk people NOGG.

The ROS says monitoring appointments usually happen about three months and one year after starting, with a formal review after about five years on tablets or around three years on injections. Options then include continuing, a treatment pause of one to two years, switching or stopping. Ibandronate keeps helping bones for about one to two years after you stop. If treatment is paused, NOGG recommends reassessing fracture risk with FRAX after 18 months to decide whether to restart.

How does ibandronic acid compare with other osteoporosis treatments?

Ibandronic acid offers the least frequent tablet routine, but it is usually considered after another drug has been tried, partly because it is unclear whether it lowers hip fracture risk as much as other options.

• Alendronic acid and risedronate are weekly (or daily) tablets with a 30-minute wait rather than 60.
• Zoledronic acid is a once-a-year drip that avoids tablets entirely.
• Denosumab (Prolia) is a six-monthly injection often used when bisphosphonates are not suitable.
• Bone-building drugs such as teriparatide and romosozumab are for very high fracture risk.

Our guide to osteoporosis treatment explains how UK doctors choose between them.

How can you keep track of your bones on treatment?

Your GP or specialist reviews your fracture risk over time, sometimes with a repeat DXA scan, because bone density changes slowly. Calcium, vitamin D, weight-bearing exercise and falls prevention all support the medicine. If you want an extra check between appointments, a Screen My Bones bone health assessment uses radiation-free REMS ultrasound that can be repeated for monitoring. It does not replace DXA for a diagnosis or NHS treatment decisions. Keep taking your treatment as prescribed and speak to your doctor before making any change.

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This article is part of our bone health series. It is general information, not a substitute for advice from your own doctor or pharmacist.