What are the indications for bisphosphonates in the treatment of elderly patients with osteoporosis?

From the Guidelines

Bisphosphonates are indicated in elderly patients with osteoporosis to reduce the risk of hip and vertebral fractures, particularly in those with a T-score of -2.5 or lower, or those with a T-score between -1.0 and -2.5 with high fracture risk based on FRAX assessment or history of fragility fractures. The treatment of osteoporosis in elderly patients involves the use of bisphosphonates, such as alendronate, risedronate, zoledronic acid, and ibandronate, which have been shown to reduce the risk of fractures 1. According to the American College of Physicians guideline, bisphosphonates are recommended for the treatment of osteoporosis in women with known osteoporosis to reduce the risk of hip and vertebral fractures 1.

Key Points to Consider

• The use of bisphosphonates in elderly patients with osteoporosis has been shown to reduce the risk of hip and vertebral fractures by 36-68% compared to placebo 1.
• The treatment duration for bisphosphonates typically ranges from 3-5 years, after which a drug holiday may be considered based on fracture risk reassessment 1.
• Common bisphosphonates include alendronate (70mg weekly), risedronate (35mg weekly or 150mg monthly), zoledronic acid (5mg IV yearly), and ibandronate (150mg monthly oral or 3mg IV quarterly).
• Potential side effects of bisphosphonates include gastrointestinal issues, osteonecrosis of the jaw (rare), and atypical femur fractures with long-term use 1.
• Contraindications for bisphosphonates include severe renal impairment (CrCl <30-35 mL/min), hypocalcemia, and esophageal abnormalities that delay emptying 1.

Administration and Monitoring

• Oral bisphosphonates should be taken with a full glass of water after overnight fasting, and patients should remain upright for 30-60 minutes afterward.
• Bone density monitoring is not recommended during the 5-year pharmacologic treatment period for osteoporosis in women 1.
• The decision to treat osteopenic women 65 years of age or older who are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications 1.

From the FDA Drug Label

Risedronate sodium is a bisphosphonate in a delayed-release formulation and is indicated for treatment of postmenopausal osteoporosis (1.1)

The indications for bisphosphonates in the treatment of elderly patients with osteoporosis are for the treatment of postmenopausal osteoporosis.

• Key Indication: Treatment of postmenopausal osteoporosis
• Patient Population: Elderly patients with postmenopausal osteoporosis 2

From the Research

Indications for Bisphosphonates in Elderly Patients with Osteoporosis

• Bisphosphonates are indicated for the prevention and treatment of osteoporosis in elderly patients, as they reduce the risk of fracture by suppressing bone resorption and increasing bone strength 3.
• The use of bisphosphonates is recommended for patients with a high risk of fracture, including those with a low hip T-score, previous major osteoporotic fracture, or those who fracture on therapy 4.
• Bisphosphonates have been shown to be effective in increasing bone mineral density (BMD) and decreasing the incidence of fractures in patients with postmenopausal osteoporosis and glucocorticoid-induced osteoporosis 5.
• The benefits of bisphosphonate therapy, including the prevention of fractures, outweigh the risks, such as osteonecrosis of the jaw and atypical femur fractures, in patients with established osteoporosis or those at high risk of fracture 6.
• Bisphosphonates are widely used in the treatment of osteoporosis in postmenopausal women and older men, and are also effective in women with osteopenia, in whom the majority of fractures occur 7.

Patient Selection and Treatment Duration

• Patient selection for bisphosphonate therapy should be based on an assessment of fracture risk, including factors such as age, sex, and BMD 4.
• The duration of bisphosphonate therapy should be individualized, with consideration of the patient's fracture risk and response to treatment 4.
• For patients at high risk of fracture, continuation of bisphosphonate therapy for up to 10 years (oral) or 6 years (intravenous) may be considered, with periodic evaluation 4.
• A drug holiday of 2 to 3 years may be considered for patients not at high fracture risk after 3 to 5 years of bisphosphonate treatment 4.