From the Guidelines
If a patient shows no response to Fosamax (alendronate) after one year of treatment for osteoporosis, the next step would be to switch to a different medication class, such as denosumab (Prolia) 60 mg subcutaneously every 6 months, as it works through a different mechanism than bisphosphonates by inhibiting RANK ligand, and has been shown to reduce the risk of vertebral and nonvertebral fractures 1. When considering a switch, it is essential to confirm that the patient has been taking Fosamax correctly and verify treatment failure through repeat bone mineral density testing and assessment of bone turnover markers.
- Ensure adequate calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) intake, as insufficient levels can limit response to osteoporosis medications 1.
- The choice of second-line agent should be individualized based on the patient's fracture risk, comorbidities, and contraindications to specific medications.
- Anabolic agents such as teriparatide (Forteo) 20 mcg subcutaneously daily for up to 24 months, or romosozumab (Evenity) 210 mg subcutaneously monthly for 12 months, could also be considered as they build new bone rather than just preventing bone loss like bisphosphonates.
- Clinicians should assess baseline risk for fracture based on individualized assessment of bone density, history of fractures, response to prior treatments for osteoporosis, and multiple risk factors for fractures, and consider the benefits and harms of treatment, including the potential for long-term harms with bisphosphonate therapy 1.
From the Research
Next Steps in Osteoporosis Management
If there is no response to Fosamax (alendronate) in a year, the following options can be considered:
- Transitioning to other therapies, such as zoledronic acid, strontium ranelate, denosumab, or teriparatide, which may help maintain or increase bone mineral density (BMD) 2
- Teriparatide therapy for a limited time, followed by anti-resorptive treatment to prevent loss of bone gained 2
- Re-evaluation of the patient's treatment plan, considering factors such as calcium and vitamin D intake, treatment adherence, and fracture risk 3
Criteria for Treatment Failure
Treatment failure can be defined as:
- Incident major fracture within the first treatment year
- More than one minor insufficiency fracture
- Bone mineral density decrease by at least 0.03 g/cm(2) after 5 years or earlier in the event of a minor fracture 3
Long-term Treatment with Bisphosphonates
Long-term use of bisphosphonates, such as alendronate, can result in persistent antifracture and BMD-increasing effects beyond 3 years of treatment 4 Regular monitoring of BMD and fracture risk is necessary to determine whether treatment can be stopped or should be reinitiated 4