From the Guidelines
There is no specific age limit for starting bisphosphonates, but treatment decisions should be individualized based on fracture risk, bone mineral density, and overall health status. According to the most recent guideline from the American College of Rheumatology 1, screening for fracture risk should be assessed by using FRAX and by performing BMD using dual-energy x-ray absorptiometry (DXA) with vertebral fracture assessment (VFA) testing or spinal x-rays as soon as possible after initiation of ≥2.5 mg/day GC treatment for >3 months in patients ≥40 years of age.
Some key points to consider when deciding to start bisphosphonates include:
- Fracture risk: Patients with high or very high fracture risk should be offered osteoporosis (OP) therapy, with oral bisphosphonates strongly recommended over no treatment in high or very high fracture risk adults 1.
- Bone mineral density: BMD with VFA testing or spinal x-ray is advised in patients <40 years, as FRAX is not validated in this population 1.
- Overall health status: Clinicians should carefully consider comorbidities, life expectancy, fall risk, and potential for medication adherence, particularly in elderly patients (over 80-85 years) 1.
- Renal function: Bisphosphonates are generally not recommended for patients with creatinine clearance below 30-35 ml/min 1.
- Dental examinations: Patients should have dental examinations to minimize risk of osteonecrosis of the jaw before starting treatment 1.
- Vitamin D and calcium levels: These should be optimized before starting treatment 1.
Bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly), ibandronate (150mg monthly), and zoledronic acid (5mg IV yearly) are commonly prescribed for postmenopausal women and men over 50 with osteoporosis or high fracture risk. However, the decision to initiate treatment with bisphosphonates in any premenopausal woman should be made on a case-by-case basis, considering individual fracture risk and potential medication-related adverse effects 1.
From the Research
Age Limit for Starting Bisphosphonates
There is no specific age limit mentioned in the studies for starting bisphosphonates. However, the following points can be considered:
- The studies focus on the treatment of postmenopausal osteoporosis, which typically occurs in older adults 2, 3, 4, 5.
- The treatment duration and discontinuation of bisphosphonates are discussed, but no specific age limit for starting treatment is mentioned 2, 3, 4, 5.
- The selection of osteoporosis treatment should be individualized and based on various factors, including underlying fracture risk, medical comorbidities, and medication burden 6.
Treatment Duration and Discontinuation
The following points can be considered regarding treatment duration and discontinuation:
- Discontinuation of bisphosphonates should be considered in patients who have been treated for more than five years with alendronate, risedronate, or zoledronic acid 2.
- A "drug holiday" can be recommended if the patient has not experienced fractures before or during therapy and the fracture risk is low 2.
- The duration of the "drug holiday" depends on the drug used, with suggested durations of 1-2 years for risedronate, 3-5 years for alendronate, and 3-6 years for zoledronic acid 2, 3.
- Close monitoring is suggested after discontinuation of denosumab due to the possibility of rebound fractures 2.
Patterns of Bisphosphonate Use
The following points can be considered regarding patterns of bisphosphonate use:
- Most adherence studies only consider treatment following a first prescription, but extended follow-up shows that 60% of seniors starting oral bisphosphonate therapy are exposed for ≥ 3 years 4.
- The median length of long-term therapy was 7.0 years for women and 6.1 years for men, with 48% continuing therapy ≥ 5 years 4.
- Only 20% experienced a treatment gap before long-term therapy, yet 50% experienced a treatment gap of ≥ 120 days after a median 5.3 years of therapy 4.