After how long should a 62-year-old on bisphosphonates (bone resorption inhibitors) have a drug holiday?

Bisphosphonate Drug Holiday Timing for a 62-Year-Old Patient

Clinicians should consider stopping bisphosphonate treatment after 3-5 years of use in a 62-year-old patient, followed by a drug holiday of 2-3 years if the patient is at moderate risk for fracture. 1, 2

Risk Assessment to Guide Drug Holiday Duration

The decision regarding bisphosphonate drug holiday should be based on a structured assessment of fracture risk:

Low-Risk Patients

• T-score > -2.0
• No history of fragility fractures
• Few clinical risk factors
• Recommendation: 3-5 year drug holiday, with reassessment of fracture risk periodically 2

Moderate-Risk Patients (Most 62-year-olds fall here)

• T-score between -2.0 and -2.5
• FRAX score indicating elevated 10-year fracture risk
• Multiple clinical risk factors
• Recommendation: 2-3 year drug holiday, then reassess 2

High-Risk Patients

• T-score ≤ -2.5 at hip or spine
• History of fragility fracture during/after therapy
• New fracture while on drug holiday
• Continuing glucocorticoid therapy ≥7.5mg prednisone daily
• Significant BMD loss (≥10% per year) during holiday period
• Recommendation: Shorter drug holiday (1 year) or immediate continuation of therapy 2

Monitoring During Drug Holiday

• Bone mineral density testing every 1-2 years 2
• Clinical assessment for new fractures
• Evaluation of bone turnover markers if available
• Reassessment of overall fracture risk

Rationale for Drug Holiday

The American College of Physicians guideline indicates that increasing bisphosphonate therapy beyond 5 years may reduce risk for new vertebral fractures but not other fractures, while increasing risk for long-term adverse effects 1:

• Atypical femoral fractures (3.0-9.8 cases per 100,000 patient-years) 2
• Osteonecrosis of the jaw (<1 case per 100,000 person-years) 2

Special Considerations

1. Bisphosphonate type matters: Alendronate and zoledronic acid have longer skeletal retention than risedronate, potentially allowing for longer drug holidays 3

2. Glucocorticoid use: If the patient is on ongoing glucocorticoid therapy (≥7.5mg prednisone daily), bisphosphonate therapy should be continued rather than implementing a drug holiday 2

3. Recent fractures: Patients with recent fractures should continue therapy rather than taking a drug holiday 3

4. Age consideration: At 62, this patient is relatively young for osteoporosis treatment, which may allow for a slightly longer drug holiday than an older patient with similar risk factors 4

When to Restart Therapy

Bisphosphonate therapy should be restarted if during the drug holiday period:

• Bone mineral density decreases significantly (≥5%)
• A new fragility fracture occurs
• Clinical risk factors for fracture significantly increase
• The drug holiday has reached its recommended duration based on risk category 2, 3

Common Pitfalls to Avoid

1. Stopping without a plan: All patients receiving bisphosphonate therapy should have the need for continued therapy reevaluated periodically 5

2. One-size-fits-all approach: The FDA label notes that patients at low risk for fracture should be considered for drug discontinuation after 3-5 years, but this must be individualized based on risk assessment 5

3. Failure to monitor: Regular monitoring during the drug holiday is essential to detect significant bone loss or new fractures that would warrant resumption of therapy 2

4. Ignoring rebound bone loss: Some patients may experience accelerated bone loss after discontinuation, particularly with denosumab (not a bisphosphonate) 4