Red flags to teach & report
Esophagitis / erosion — new heartburn, painful or difficult swallowing, chest pain. Hold the drug and notify the prescriber. Do not chew or suck the tablet (oral ulcers).
Osteonecrosis of the jaw — rare; jaw pain, loose teeth, non-healing socket. Dental exam and needed work before starting.
Atypical femoral fracture — new dull thigh or groin ache after long-term use. Report before it completes.
Check before the first dose: correct hypocalcemia and vitamin D deficiency first (the drug drives calcium into bone and can worsen a low level). Check renal function — oral agents are avoided at CrCl below about 30–35 mL/min. Baseline DEXA to follow response.