Is it safe to restart Fosamax (alendronate) after a hip fracture?

Restarting Fosamax After Hip Fracture

Yes, alendronate (Fosamax) should be restarted after hip fracture once the surgical wound shows evidence of healing, typically around 14 days post-surgery, as patients with hip fractures are at very high risk for subsequent fractures and require pharmacologic treatment to prevent mortality and morbidity. 1

Rationale for Treatment After Hip Fracture

• Hip fracture patients have the highest post-fracture mortality risk, particularly in the first year, making secondary fracture prevention critical for survival 1
• Alendronate is a first-choice agent for fracture prevention in postmenopausal women and men over 50 with osteoporosis, demonstrating reductions in vertebral fractures (45%), nonvertebral fractures (23%), and hip fractures (53%) in secondary prevention 1, 2
• A hip fracture itself establishes the diagnosis of osteoporosis and represents "very high fracture risk" regardless of BMD T-score, warranting immediate pharmacologic intervention 1, 3

Timing of Restart

Restart alendronate approximately 14 days after hip fracture surgery when:

• The surgical wound shows evidence of healing 1
• Sutures or staples have been removed 1
• There is no significant swelling, erythema, or drainage 1
• There is no ongoing non-surgical site infection 1

Evidence Supporting Early Initiation

• Alendronate given immediately after surgical hip fracture repair (within 6 weeks) produces significant increases in proximal femoral BMD and decreases in bone turnover markers over 12 months 4
• Patients who restart bisphosphonates within 4 weeks after surgery have better outcomes than those who delay longer 1
• Both alendronate and raloxifene have favorable effects on trochanter and total hip BMD when started in the early post-fracture period 5

Clinical Benefits Specific to Hip Fracture Patients

Alendronate provides robust hip fracture protection through multiple mechanisms:

• Reduces hip fracture risk by 40-55% in postmenopausal women with prior fractures 2, 6
• Increases hip BMD by 2.57% at total hip and 2.96% at trochanter within one year of treatment after hip fracture 4
• Decreases cortical porosity and improves hip structural geometry (cortical thickness, cross-sectional area, section modulus) 6
• Strongly suppresses bone turnover markers, with each 1 standard deviation reduction in bone-specific alkaline phosphatase associated with 39% fewer hip fractures 6

Dosing Recommendations

Use alendronate 70 mg once weekly rather than daily dosing:

• Once-weekly regimen provides better patient compliance and persistence compared to daily dosing, leading to greater anti-fracture efficacy 6
• Weekly dosing is as effective as 10 mg daily for increasing BMD 7

Essential Concurrent Therapy

Always prescribe calcium and vitamin D supplementation with alendronate:

• Calcium 1000-1200 mg/day (diet plus supplementation if needed) 1
• Vitamin D 800 IU/day 1
• Vitamin D supplementation at this dose is associated with 15-20% reduction in non-vertebral fractures and falls 1

Safety Considerations

Alendronate is generally well tolerated when taken as recommended:

• No statistically significant difference in serious adverse events compared to placebo in large clinical trials 1, 2
• Upper GI adverse events (abdominal pain, dyspepsia) are the most common but typically transient 7
• Provide specific dosing instructions to minimize GI risk: take with full glass of water, remain upright for 30 minutes, take on empty stomach 7

Rare but Serious Adverse Events

• Atypical femoral fractures and osteonecrosis of the jaw are rare complications of long-term bisphosphonate use, but the benefits far outweigh risks in the immediate post-hip fracture period 2
• These concerns should not delay initiation in high-risk hip fracture patients 1

Duration of Treatment

Continue alendronate for 3-5 years initially:

• Reevaluate fracture risk after 3-5 years to determine need for continued therapy 1
• Patients who remain at high risk (such as those with prior hip fracture) should continue treatment beyond 5 years 1
• Hip fracture patients typically remain at very high risk and often require longer treatment duration 3

Alternative Agents if Alendronate Cannot Be Used

For patients with contraindications to oral bisphosphonates:

• Zoledronic acid (intravenous) is the only drug specifically studied immediately after hip fracture and reduces subsequent fractures 1
• Denosumab (subcutaneous) is appropriate for patients with oral intolerance, dementia, malabsorption, or non-compliance 1
• Teriparatide or romosozumab may be considered for very severe osteoporosis with multiple fractures 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for "complete healing" beyond 2 weeks if wound is healing appropriately—the risk of subsequent fracture is highest in the first year 1
• Do not withhold treatment due to concerns about atypical fractures in the immediate post-hip fracture period—the absolute risk is extremely low and vastly outweighed by benefits 1
• Do not forget calcium and vitamin D—these are essential components of all osteoporosis treatment regimens 1
• Do not assume the patient was non-compliant with prior alendronate if they fractured—hip fractures can occur despite treatment, though risk is substantially reduced 6