What should I do if I had a fragility fracture, took alendronate (bisphosphonate) for 2 years, then stopped, and now have osteopenia shown on a Dual-Energy X-ray Absorptiometry (DEXA) scan?

From the Guidelines

You should consult with your healthcare provider about possibly restarting bisphosphonate therapy, given your history of fragility fracture and current osteopenia. Since you previously took alendronate for 2 years and have now developed osteopenia after stopping, you may benefit from resuming treatment. Typically, alendronate is prescribed at 70mg once weekly or 10mg daily 1. In addition to medication, ensure you're getting adequate calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) through diet or supplements. Regular weight-bearing exercise like walking, jogging, or resistance training for 30 minutes most days of the week is also important. Bisphosphonates work by inhibiting bone resorption, helping maintain bone density and reduce fracture risk 1. The "drug holiday" you took is common practice, but with osteopenia now present and your history of fragility fracture, you're at increased risk for future fractures. Your doctor may also consider other medications like denosumab (Prolia) or anabolic agents depending on your specific situation and fracture risk assessment 1. Some key points to consider when deciding on treatment include:

• The importance of adherence to treatment, as poor adherence can lead to reduced effectiveness and increased risk of fractures 1
• The potential side effects of bisphosphonates, such as gastrointestinal symptoms, and the need for regular monitoring 1
• The potential benefits of other medications, such as denosumab, which has been shown to reduce the risk of vertebral fractures 1
• The need for regular follow-up and assessment of fracture risk to determine the best course of treatment 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps After Stopping Alendronate

If you had a fragility fracture, took alendronate for 2 years, then stopped, and now have osteopenia shown on a DEXA scan, consider the following:

• Re-evaluation of bone health: Given the diagnosis of osteopenia after stopping alendronate, it is essential to reassess bone health and fracture risk 2.
• Treatment options: Bisphosphonates, such as alendronate, are a standard treatment for osteoporosis, but concerns about oversuppression of bone turnover on long-term treatment can be addressed with a drug holiday, depending on the patient's fracture risk 2.
• Alternative treatments: Anabolic agents like teriparatide can be considered for patients at high risk of fracture, such as those with declining bone mineral density despite bisphosphonate treatment 2.
• Comparative effectiveness of bisphosphonates: Studies have shown that different bisphosphonates, including alendronate, ibandronate, risedronate, and zoledronate, have varying effectiveness in preventing fragility fractures, with zoledronate being the most effective in preventing vertebral fractures 3.
• Non-pharmacologic treatment: Calcium and vitamin D supplementation can be considered as part of a comprehensive treatment plan to prevent future fractures 4, 5.
• Regular monitoring: Regular DEXA scans and monitoring of bone health can help identify any changes in bone density and inform treatment decisions 6.

Considerations for Future Fracture Risk

When considering the next steps, it is crucial to take into account the following:

• History of fragility fracture: A history of fragility fracture is a strong risk factor for future fractures, emphasizing the need for ongoing evaluation and treatment 4.
• Bone quantity, quality, and turnover: Assessing these factors can help identify patients at increased fracture risk and inform treatment decisions 2.
• Patient-specific factors: Consideration of individual patient factors, such as age, sex, and medical history, can help guide treatment choices and minimize the risk of future fractures 5.