Short answer: It depends on the medicine and how low kidney function is. Fosamax is not recommended and Reclast is not used below a creatinine clearance of 35 mL/min; Actonel and ibandronate are not recommended below 30. Prolia, Evenity, Forteo and Tymlos need no dose change, but Prolia has a boxed warning for severe low calcium in advanced kidney disease, and Evenity flags the same risk.
Kidney function in these labels is measured as creatinine clearance (CrCl) or eGFR, both in mL/min. See eGFR.
| Medicine | Kidney limit | Section |
|---|---|---|
| Fosamax (alendronate) | Not recommended below CrCl 35; no change from 35 to 60 | 5.6, 8.6 |
| Actonel (risedronate) | Not recommended below CrCl 30, for lack of experience | 8.6 |
| Ibandronate tablets | Not recommended below CrCl 30 | 5.6 |
| Reclast (zoledronic acid) | Contraindicated below CrCl 35 or with acute kidney injury | 4, 5.3 |
| Prolia (denosumab) | No dose change; boxed warning for severe low calcium below eGFR 30, including dialysis | Boxed, 5.1, 8.6 |
| Evenity (romosozumab) | No dose change; higher low calcium risk at eGFR 15 to 29 or on dialysis | 5.3, 8.7 |
| Forteo (teriparatide) | Higher blood levels in severe impairment; effect on kidney bone disease unknown | 8.7 |
| Tymlos (abaloparatide) | No dose change for mild, moderate or severe impairment | 8.6 |
The Prolia boxed warning says people with eGFR under 30, including those on dialysis, are at greater risk of severe hypocalcemia, with hospitalizations, life-threatening events and deaths reported. A kidney-related bone disorder called CKD-MBD markedly raises the risk. Before starting, the label lists checks of parathyroid hormone, calcium and vitamin D levels, then calcium checks weekly for the first month and monthly after that, with calcium and active vitamin D as needed.
In a study of 55 people, very low or symptomatic calcium occurred in no one with normal kidneys, 10% with CrCl 50 to 80, 29% with CrCl under 30 and 29% on hemodialysis. Stopping Prolia has its own risks, covered in stopping Prolia.
Reclast is given as a once-yearly infusion. The label says to calculate creatinine clearance from a blood test before each dose, to hold the dose if a person seems dehydrated, to give no more than 5 mg and to run the infusion over at least 15 minutes. Kidney failure has occurred after zoledronic acid, especially with existing kidney problems, older age, other kidney-straining medicines, diuretics or severe dehydration (section 5.3).
Kidney disease can also change how bones break down, so the choice of medicine often involves the kidney team as well. Recent kidney numbers, calcium and vitamin D levels, and dialysis plans are worth bringing to the visit. Dose Track can keep injection and infusion dates next to lab results, which helps with Prolia's calcium checks.
Read more on Dose Track: eGFR · Bisphosphonate · Prolia side effects · Fosamax vs Prolia