Duration of bisphosphonate therapy

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Recently there has been much debate over the optimum duration of bisphosphonate therapy however there is virtually no evidence to base this guideline on. On one hand the risk of over suppression of the bone and atypical fractures related to this e.g. subtrochanteric fractures has been cited. However, this remains an extremely rare occurrence and in virtually every case bisphosphonates prevent many hundreds of fragility fractures relative to the number of atypical fractures attributed to long term bisphosphonate use. There is no evidence for an increase in hip fracture rates with long term bisphosphonate therapy. (Pazianas et al Osteoporos Int (2012) 23:2873-2884). Other justifications for a “drug holiday” from bisphosphonates relate to economic arguments and patient quality of life issues.

Until there is evidence to state that bisphosphonates have continuing anti-fracture efficacy after a course of 5 years the following guidance should be considered and combined with what is practical with the individual patient considering ability to take medication and life expectancy.

Is the patient, or does the patient have: Age over 75 at start of bisphosphonate therapy and low trauma fracture within past 10 years or continuing corticosteroid 7.5mg/d? Multiple vertebral fractures or FRAX risk >30% (10 year major osteoporotic risk)? – must have DXA result available. If no baseline then organise this now. Frequent falls/ frail?

If the answer to any of the above is YES: Continue bisphosphonate / stontium long term.

If the answer to all is NO: Treatment holiday can be considered (5 years for alendronate and 2 years for other bisphosphonates) Do not give a treatment holiday from denosumab and perhaps not required for strontium ranelate. If further fractures sustained during holiday period then restart bisphosphonate long term. Re-refer using DXA form at end of treatment holiday – we may not need to rescan but can give advice by letter for individual cases. Please highlight “treatment holiday ended” on referral form in “other” section.