From the Guidelines
Continuing alendronate for a total of 3-5 years is recommended for most patients with osteoporosis who have shown improvement on DEXA scans, as this duration has been associated with a reduction in fracture risk 1. When considering whether to continue alendronate after 2 years with improved bone density on DEXA, several factors should be taken into account, including the patient's fracture risk profile, benefits, harms, and costs of medications. According to the American College of Physicians guideline update from 2017 1, treatment with pharmacologic therapy, such as alendronate, for 5 years is recommended for osteoporotic women to reduce the risk for hip and vertebral fractures. Some key points to consider include:
- The benefits of treatment with alendronate, including reduction in vertebral and nonvertebral fracture risk 1
- The potential harms of treatment, such as mild upper GI symptoms, atypical subtrochanteric fracture, and osteonecrosis of the jaw 1
- The importance of individualizing treatment decisions based on patient preferences, fracture risk profile, and benefits, harms, and costs of medications 1 After 3-5 years of treatment, a drug holiday may be considered if the patient's T-score has improved to better than -2.5 and they haven't had recent fractures. However, high-risk patients, such as those with previous fragility fractures, very low bone density, or on long-term steroids, may benefit from longer treatment, potentially up to 10 years. It is essential to discuss specific fracture risk factors, including age, gender, previous fractures, family history, and lifestyle factors, with a doctor to determine the optimal duration of therapy for each individual situation.
From the FDA Drug Label
In osteoporosis treatment studies alendronate sodium 10 mg/day decreased the markers of bone formation, osteocalcin and bone specific alkaline phosphatase by approximately 50%, and total serum alkaline phosphatase by approximately 25 to 30% to reach a plateau after 6 to 12 months
The decision to continue alendronate after 2 years with improved bone density on DEXA should be based on the individual patient's risk factors and bone health status. Continuation of therapy may be considered if the patient has a history of osteoporotic fractures, a high risk of future fractures, or if the bone density has not yet reached a stable level. However, the FDA label does not provide specific guidance on the duration of treatment, and the decision to continue or stop therapy should be made on a case-by-case basis, taking into account the patient's overall health and response to treatment 2.
- Key factors to consider when deciding whether to continue alendronate include:
- The patient's bone density and risk of future fractures
- The presence of any underlying medical conditions that may affect bone health
- The patient's response to treatment and any potential side effects
- The patient's preferences and values regarding continued treatment
It is essential to weigh the benefits and risks of continued therapy and to monitor the patient's bone health regularly to determine the best course of action 2.
From the Research
Continuation of Alendronate Therapy
After two years of alendronate treatment with improved bone density on DEXA, the decision to continue alendronate therapy depends on several factors.
- Efficacy of Alendronate: Studies have shown that alendronate is effective in increasing bone mineral density (BMD) and reducing the risk of fractures in postmenopausal women with osteoporosis 3, 4, 5.
- Duration of Therapy: The optimal duration of alendronate therapy is not well established, but studies have shown that continued treatment for up to 2 years can maintain or further increase BMD 4.
- Risk of Fractures: Alendronate has been shown to reduce the risk of vertebral fractures by 47-56% in postmenopausal women with osteoporosis 3.
- Discontinuation of Therapy: Discontinuation of alendronate therapy after 1-2 years may lead to a loss of BMD gains, particularly in patients with glucocorticoid-induced osteoporosis 6.
Factors to Consider
When deciding whether to continue alendronate therapy, the following factors should be considered:
- BMD measurements: Regular BMD measurements can help monitor the effectiveness of alendronate therapy and inform decisions about continued treatment.
- Fracture risk: Patients with a high risk of fractures may benefit from continued alendronate therapy.
- Side effects: The risk of side effects, such as gastrointestinal adverse events, should be weighed against the benefits of continued treatment.
- Alternative treatments: Other treatments, such as calcium and vitamin D supplementation, may be considered in addition to or instead of alendronate therapy 7.