At what age is Fosamax (alendronate) no longer recommended for osteoporosis treatment?

No Specific Age Limit for Discontinuing Alendronate in Osteoporosis Treatment

There is no specific age at which Fosamax (alendronate) is universally contraindicated or not recommended for osteoporosis treatment; instead, treatment decisions should be based on fracture risk assessment, potential benefits, and risk of adverse effects.

Factors to Consider When Evaluating Alendronate Continuation

Fracture Risk Assessment

• Treatment decisions should prioritize patients at highest risk for fracture, regardless of age 1
• Factors indicating high fracture risk include:
  • Previous osteoporotic fracture
  • T-score ≤ -2.5
  • FRAX 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20% 2

Duration of Treatment

• After 5 years of oral bisphosphonate treatment, patients should be reassessed 1:
  • For patients at moderate-to-high fracture risk who continue glucocorticoid treatment, continue active treatment beyond 5 years
  • For patients at low risk who discontinue glucocorticoid treatment, discontinue the bisphosphonate but continue calcium and vitamin D

Benefit-Risk Considerations

• Benefits of alendronate include:

  • Reduction in vertebral fractures by approximately 45-55% 3
  • Reduction in non-vertebral fractures by approximately 17-20% 3
  • Reduction in hip fractures by approximately 24-51% in high-risk patients 3

• Potential risks to consider, especially with advancing age:

  • Atypical femoral fractures (rare but serious)
  • Osteonecrosis of the jaw (rare)
  • Esophageal irritation
  • Fall risk and polypharmacy interactions 1

Monitoring and Reassessment

• Reassess fracture risk periodically, especially after 3-5 years of treatment 1
• Consider a drug holiday after 5 years in stable patients with moderate risk
• Continue treatment in high-risk patients (prior fracture, ongoing glucocorticoid use, very low BMD) 1, 2
• Follow-up DXA scan in 1-2 years to assess bone mineral density response to therapy 2

Special Considerations for Older Adults

• For older adults with multiple comorbidities or polypharmacy concerns:
  • Evaluate risk of falls and drug interactions
  • Consider denosumab as an alternative if bisphosphonates are contraindicated 1
  • Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake 1, 2

Algorithm for Decision-Making

1. Assess current fracture risk (FRAX score, T-score, prior fractures)
2. Evaluate treatment duration (if already on alendronate)
3. Consider comorbidities, polypharmacy, and fall risk
4. If high fracture risk persists: continue treatment regardless of age
5. If moderate risk after 5 years: consider drug holiday with periodic reassessment
6. If low risk and stable: discontinue bisphosphonate but maintain calcium and vitamin D

The decision to continue or discontinue alendronate should be based on an individual's current fracture risk profile rather than age alone, as the benefits of fracture prevention may outweigh potential risks even in very elderly patients with high fracture risk.