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We describe the cases of three patients, under the care of the rheumatology service, who presented with osteonecrosis of the jaw whist on oral bisphosphonate therapy. The first case is of a 74-year-old woman with a 12 year history of sero-negative inflammatory arthritis, having been on oral steroids for 11 years, Methotrexate for the preceding 6 years, and oral bisphosphonates for 9 years. Clinical and radiographic examination revealed extensive jaw necrosis. The second patient was a 72-year-old woman with temporal arteritis, on long term oral steroids, and oral bisphosphonates presenting with jaw osteonecrosis. The third case is of an 81-year-old lady with a diagnosis of Polymyalgia Rheumatica on reducing dose of prednisolone along with calcium and vitamin D3 and oral bisphosphonate therapy as part of steroid induced prophylaxis guidelines. On reviewing the literature regarding bisphosphonate-associated osteonecrosis of the jaw, there is indeed recognition of this occurring with oral bisphosphonates. However, this is far less common than with intravenous preparations. Reports to the UK MHRA regarding adverse reactions have shown 53 cases of osteonecrosis of the jaw associated with oral bisphosphonates, but this is thought to represent under-reporting. We suggest consideration of patient counselling and consent, and preventive dental work prior to initiation of oral bisphosphonate therapy.

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Summary As life expectancy of sickle cell disease improves, it can be expected that these individuals will increasingly require complex vascular surgery. We present the first reported case of endovascular repair of an abdominal aortic aneurysm in this patient group. Our patient, despite being aware of the lack of published clinical experience in such cases, strongly favoured definitive repair of his 6.3cm aneurysm. Careful consideration of the surgical options, in consultation with haematologists and anaesthesia personnel, concluded that an endovascular approach was likely to offer the lowest risk of an acute sickling crisis. The multidisciplinary team agreed an individualised perioperative care plan, which included arrangements for prior patient education, pre‐operative exchange transfusion, haemoglobin profile targets, strategies for minimising sickling precipitants and appropriate postoperative care. This collaborative approach, which we believe to be mandatory in such cases, resulted in an uneventful procedure, smooth recovery and a satisfied patient who has returned to normal activities.