From the Guidelines
Yes, a patient with a history of fragility fracture and current diagnosis of osteopenia on DEXA should continue taking alendronate, as the presence of a prior fragility fracture significantly increases the risk of future fractures, regardless of bone mineral density measurements 1. Alendronate, typically dosed at 70mg once weekly, works by inhibiting osteoclast-mediated bone resorption, thereby increasing bone mass and reducing fracture risk.
Key points to consider:
- The history of fragility fracture indicates a higher fracture risk that warrants continued pharmacologic intervention, even with a current diagnosis of osteopenia rather than osteoporosis 1.
- Treatment should generally continue for at least 3-5 years, with periodic reassessment of fracture risk.
- The medication should be taken first thing in the morning with a full glass of water, and the patient should remain upright for at least 30 minutes afterward to prevent esophageal irritation.
- Adequate calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation should accompany bisphosphonate therapy.
- After 3-5 years of treatment, the physician should reassess the patient's fracture risk to determine whether to continue therapy, take a drug holiday, or switch to an alternative treatment, considering the latest evidence-based guidelines for osteoporosis management 1.
It is essential to weigh the benefits and harms of treatment, including the potential for mild gastrointestinal symptoms, atypical subtrochanteric fractures, and osteonecrosis of the jaw associated with bisphosphonates 1. However, the most recent and highest-quality study supports the continuation of alendronate in patients with a history of fragility fracture and osteopenia 1.
From the Research
Patient Considerations
- A patient with a history of fragility fracture and current diagnosis of osteopenia, as shown on Dual-Energy X-ray Absorptiometry (DEXA), may still benefit from taking alendronate (bisphosphonate) to reduce the risk of future fractures 2, 3.
- The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <-2.5) or history of fragility fracture, which may include patients with osteopenia 3.
- However, the selection of osteoporosis treatment should be individualized and based on a variety of factors, including underlying fracture risk, medical comorbidities, medication burden, as well as fracture risk reduction profiles, modes of administration, and side effects of treatment options 4.
Treatment Efficacy
- Bisphosphonates, such as alendronate, have been shown to be effective in reducing the risk of fragility fractures, although differences in efficacy across drugs are small 2.
- Teriparatide, denosumab, and zoledronate may have a higher risk reduction of fractures compared to alendronate, but the differences are not statistically significant 2.
- Calcium and vitamin D supplementation may also be effective in reducing the risk of hip fractures, especially when given in combination 2.
Clinical Practice
- Despite the availability of therapeutic agents that reduce fracture risk, most patients with fragility fractures are not evaluated for osteoporosis or treated adequately to reduce the risk of future fracture 5, 6.
- Orthopaedic surgeons and other healthcare professionals play a crucial role in ensuring that patients with fragility fractures receive appropriate evaluation and treatment to prevent future fractures 5, 6.