From the Guidelines
Bisphosphonate therapy should be initiated when your T-score is -2.5 or lower, as this indicates osteoporosis and is associated with a high risk of fractures, according to the American College of Physicians guideline update from 2017 1. When considering the initiation of bisphosphonates, it's essential to assess the patient's fracture risk, including factors such as history of fragility fractures, FRAX score, and other osteoporosis risk factors.
- The American College of Physicians recommends offering pharmacologic treatment with bisphosphonates to women with known osteoporosis (T scores ≤ –2.5) to reduce the risk of hip and vertebral fractures 1.
- The British Society of Gastroenterology consensus guidelines suggest that patients on long-term steroids should have a repeat bone densitometry at 1 year, and if stable, repeated at two to three-year intervals, but if declining, repeated annually, with a high-risk threshold for intervention being a T score of -1.5 1.
- However, the most recent and highest quality study, which is the 2019 British Society of Gastroenterology consensus guidelines, suggests that the threshold for intervention can be as high as a T score of -1.5 in certain high-risk patients, such as those on long-term steroids 1.
- It's also important to note that bisphosphonates are associated with potential side effects, such as gastrointestinal symptoms, atypical subtrochanteric fractures, and osteonecrosis of the jaw, and that patients should be informed of these risks and monitored accordingly 1.
- Before starting treatment, patients should have baseline calcium and vitamin D levels checked, and any deficiencies corrected, to ensure adequate bone health and minimize the risk of side effects.
- Common bisphosphonates include alendronate, risedronate, ibandronate, and zoledronic acid, which work by inhibiting bone resorption and increasing bone mineral density.
- Treatment duration typically ranges from 3-5 years initially, after which a drug holiday may be considered based on reassessment of fracture risk.
From the Research
Initiation of Bisphosphonates
The decision to initiate bisphosphonates is based on the patient's bone density, specifically the T-score.
- A T-score of -2.5 or lower is generally considered indicative of osteoporosis, and bisphosphonate therapy may be recommended 2.
- For patients with a T-score between -1 and -2.5, bisphosphonate therapy may be considered on an individual basis, taking into account other risk factors for osteoporosis and fractures 2.
- The European Menopause and Andropause Society (EMAS) position statement suggests that bisphosphonates should be considered for patients with a high risk of fracture, but does not specify a particular T-score threshold for initiation of therapy 3.
Factors Influencing Initiation of Bisphosphonates
Several factors can influence the decision to initiate bisphosphonates, including:
- The patient's fracture risk, with higher risk patients potentially benefiting from earlier initiation of therapy 4
- The presence of other medical comorbidities, which may affect the patient's ability to tolerate bisphosphonate therapy 4
- The patient's medication burden, with polypharmacy potentially increasing the risk of adverse effects 4
- The patient's lifestyle behaviors, such as calcium and vitamin D intake, exercise, and smoking status 2
Clinical Guidelines
Clinical guidelines recommend baseline and annual follow-up bone density monitoring for patients initiating aromatase inhibitor therapy, and bisphosphonate therapy should be prescribed for patients with osteoporosis (T score < -2.5) 2.
- The guidelines also suggest that bisphosphonate therapy be considered on an individual basis for patients with osteopenia (T score < -1) 2.