Is Fosamax (alendronate) suitable for treating osteoporosis in an 82-year-old patient with post-polio myelitis?

Alendronate (Fosamax) for Osteoporosis in an 82-Year-Old Patient with Post-Polio Myelitis

Alendronate (Fosamax) is not recommended as a first-line treatment for osteoporosis in an 82-year-old patient with post-polio myelitis due to concerns about safety, tolerability, and limited evidence in this specific population.

Assessment Considerations

• Patients with severe motor disabilities like post-polio myelitis are at increased risk for disuse osteoporosis and fractures 1
• Advanced age (82 years) combined with post-polio myelitis creates a complex clinical picture requiring careful risk-benefit assessment 2
• Bone health assessment should include:
  • Bone mineral density (BMD) via DEXA scan 2
  • Fracture risk assessment using FRAX calculation 3
  • History of previous fragility fractures 2
  • Evaluation of renal function before initiating bisphosphonate therapy 4

Safety Concerns with Alendronate in This Population

• Bisphosphonates should be used with caution in patients with impaired mobility due to:
  • Risk of esophageal irritation in patients who may have difficulty maintaining upright position for 30 minutes after taking oral bisphosphonates 5
  • Potential for reflux esophagitis in patients with limited mobility 1
  • Contraindications include inability to stand or sit upright for at least 30 minutes 3
• Renal function concerns:
  • KDIGO guidelines suggest not prescribing bisphosphonate treatment in people with GFR <30 ml/min/1.73 m² without strong clinical rationale 4
  • Renal function should be monitored in patients on bisphosphonates 2

Alternative Approaches

• For patients with severe motor disabilities who need bisphosphonate therapy, intravenous formulations may be more appropriate than oral options 1
• Calcium (1,000–1,500 mg/day) and vitamin D (800 IU/day) supplementation should be considered as baseline therapy 2
• Physical activity designed to improve spine mechanics should be encouraged as tolerated 2
• Regular monitoring of bone health is essential:
  • DEXA scan should be repeated after 1-2 years when rapid bone loss is expected 2
  • Lateral X-rays of spine for diagnosing vertebral fractures 2

Treatment Duration Considerations

• If bisphosphonate therapy is initiated despite concerns, consider limiting duration:
  • Studies suggest that after 3-5 years of treatment, there is persisting anti-fracture efficacy for 1-2 years after discontinuation 6
  • A drug holiday after 5 years may be appropriate for patients at lower fracture risk 6
  • Patients at higher risk might need treatment for up to 10 years with shorter drug holidays 6

Conclusion

For an 82-year-old patient with post-polio myelitis, the risks of oral alendronate likely outweigh the benefits. Consider alternative approaches including calcium and vitamin D supplementation, physical therapy as tolerated, and if bisphosphonate therapy is deemed necessary, an intravenous formulation may be more appropriate to avoid esophageal complications in a patient who may have difficulty maintaining an upright position after taking oral medication 1.