What is the guidance for taking a drug holiday from bisphosphonate (Bisphosphonates) in a patient with osteoporosis?

From the Guidelines

Bisphosphonate treatment should be stopped after 5 years unless the patient has a strong indication for treatment continuation, as the current evidence suggests that increasing the duration of bisphosphonate therapy to longer than 3 to 5 years reduces risk for new vertebral fractures but not risk for other fractures, and increases the risk for long-term harms. When considering a drug holiday from bisphosphonates for osteoporosis patients, it is essential to assess the individual's baseline risk for fracture based on bone density, history of fractures, response to prior treatments, and multiple risk factors for fractures 1. The decision to stop bisphosphonate treatment should be made on a case-by-case basis, taking into account the patient's overall health and fracture risk. Some key points to consider when stopping bisphosphonate treatment include:

• Continuing calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation to support bone health
• Monitoring bone density with DEXA scans every 1-2 years during the holiday period
• Resuming bisphosphonate therapy if there is significant bone density decline (>5%), a new fracture occurs, or high fracture risk develops It is also important to note that bisphosphonates accumulate in bone and continue providing anti-fracture benefits after discontinuation, which can help reduce the risks of rare but serious side effects like atypical femur fractures and osteonecrosis of the jaw, which increase with longer treatment duration 1. In terms of specific bisphosphonate medications, the guidance is generally applicable to all types, including alendronate, risedronate, ibandronate, and zoledronic acid. However, the most recent and highest quality study, published in 2023, provides the most up-to-date guidance on this topic, and its recommendations should be prioritized 1.

From the Research

Guidance for Bisphosphonate Drug Holidays in Osteoporosis Patients

The decision to take a drug holiday from bisphosphonates in patients with osteoporosis should be based on individual factors and guidelines. Key considerations include:

• The type and duration of bisphosphonate therapy used 2, 3, 4, 5, 6
• The patient's fracture risk, bone mineral density (BMD), and history of falls 2, 3, 4, 5, 6
• The potential risks and benefits of continuing or discontinuing bisphosphonate therapy 2, 3, 4, 5, 6

Recommended Duration of Bisphosphonate Drug Holidays

Studies suggest the following durations for bisphosphonate drug holidays:

• 3-5 years after oral bisphosphonate therapy for 5 years 3, 6
• 3 years after intravenous bisphosphonate therapy 6
• Up to 5 years with alendronate, 3 years with zoledronate, and 1 year with risedronate 4
• Individualized duration based on patient-specific factors, such as fracture risk and BMD 2, 5

Monitoring and Evaluation During Bisphosphonate Drug Holidays

Regular monitoring and evaluation are necessary during bisphosphonate drug holidays to assess:

• Bone turnover markers (BTMs) and BMD 2
• Fracture risk and history 2, 3, 4, 5, 6
• Patient-specific factors, such as age, weight, and medication adherence 2, 3, 4, 5, 6

Resumption of Bisphosphonate Therapy

The decision to resume bisphosphonate therapy after a drug holiday should be based on:

• Regular reassessment of BMD and fracture risk 4, 5
• Individual patient factors, such as changes in fracture risk or BMD 2, 3, 4, 5, 6