Can You Stop Alendronate if DEXA is Normal Now?
You cannot simply stop alendronate just because your DEXA scan is now normal—the decision requires reassessment of your overall fracture risk after 3-5 years of treatment, and only patients at low-to-moderate fracture risk should be considered for a bisphosphonate holiday. 1
Risk-Based Decision Algorithm
The 2019 Endocrine Society guidelines provide clear direction: after 3-5 years of alendronate treatment, you must reassess fracture risk comprehensively 1. Here's how to decide:
Continue Alendronate (No Holiday) if:
- T-score remains ≤ -2.5 at hip or spine
- Prior hip or spine fracture in your history
- Recent fracture (within past 2 years)
- 10-year hip fracture risk ≥ 3% or major osteoporotic fracture risk ≥ 20%
- Age ≥ 75 years
These patients remain at high fracture risk despite improved DEXA and should continue therapy 1, 2, 1.
Consider Bisphosphonate Holiday if:
- T-score improved to > -2.5
- No fractures during treatment
- No recent fractures (none in past 2+ years)
- Lower fracture risk by country-specific assessment tools
- Completed 5 years of oral alendronate (or 3 years of IV zoledronic acid)
What is a Bisphosphonate Holiday?
A holiday means temporary discontinuation for up to 5 years—not permanent cessation 1. This is unique to bisphosphonates because they accumulate in bone and maintain residual anti-fracture effects after stopping 1. The FLEX trial demonstrated that women stopping alendronate after 5 years maintained much of their bone density gains, though some gradual loss occurred 3.
During the Holiday:
- Reassess fracture risk every 2-4 years with repeat DEXA scans 1
- Monitor for BMD decline beyond the least significant change of your DEXA machine 2
- Check bone turnover markers if available 2
- Restart therapy earlier if BMD significantly declines, you sustain a fracture, or clinical risk factors change 1, 2
Critical Caveats
A "normal" DEXA alone is insufficient justification to stop. The guidelines emphasize that osteoporosis management strategies should be "reinforced indefinitely, much like management strategies for hypertension and hypercholesterolemia" 1. Your baseline fracture risk, age, fracture history, and other clinical factors matter more than the current T-score.
Approximately one-third of women who discontinue alendronate experience >5% bone loss at the total hip over 5 years 3. While we cannot predict who will lose bone faster, this underscores why ongoing monitoring during a holiday is essential.
Rare but Serious Long-Term Risks
The rationale for considering holidays after 5 years includes reducing risk of:
- Atypical femoral fractures (risk reduced by >80% within 3 years of stopping) 1
- Osteonecrosis of the jaw (0.001-0.21% risk, higher with longer duration) 1, 4
However, these remain extremely rare compared to the benefit of fracture prevention 1.
What NOT to Do
Never abruptly stop without a plan. Unlike other osteoporosis medications (denosumab, teriparatide, raloxifene), bisphosphonates have residual effects that make holidays feasible 1. But this is not a free pass to discontinue—it requires structured monitoring and readiness to restart.
The 2020 AACE guidelines explicitly state: "A holiday is not recommended for non-bisphosphonate antiresorptive drugs" 2, highlighting that this concept is specific to bisphosphonates like alendronate.
Practical Recommendation
Schedule a comprehensive fracture risk reassessment with your provider using tools like FRAX. If you've completed 5 years of alendronate, have no prior hip/spine fractures, your T-score is >-2.5, and your calculated fracture risk is low-to-moderate, then a monitored holiday with DEXA surveillance every 2-3 years is reasonable 1, 2. Otherwise, continue treatment—the improved DEXA reflects successful therapy, not elimination of underlying fracture risk.