First Reported Case of Oral Ulceration Induced by Improper Sodium Ibandronate Administration in a Geriatric Patient

Abstract

The prevalence of osteoporosis is increasing, and bisphosphonate (BP) medications are widely used for its treatment. Oral BP drugs carry the risk of esophageal ulcers, which can be mitigated by following the proper administration guidelines. However, cases of oral ulceration caused by misuse, such as chewing of tablets predominantly comprising alendronate sodium, have been reported globally. Herein, we report the first case of oral ulceration attributed to the misuse of sodium ibandronate.

A 92-year-old woman presented with multiple oral erosions and was hospitalized because of poor oral intake and limited mobility. The patient was on no other medication except analgesics. During an interview, she revealed her long-standing habit of crushing tablets before ingestion. The clinical history and medication use strongly suggested that the oral ulceration was caused by sodium ibandronate. Additionally, a PILL-5 assessment indicated moderate-to-severe difficulty in swallowing (score: 17). The patient’s condition improved with supportive care after discontinuing oral BP therapy, leading to pain relief, improved food intake, and discharge.

This case highlights the need for regular follow-ups to monitor medication adherence and prevent improper administration.