From the Guidelines
Bisphosphonate therapy should be individualized, and the decision for a temporary treatment discontinuation (holiday) and its duration should be based on baseline risk for fractures, type of medication, and its half-life in bone, benefits, and harms. When considering a drug holiday from bisphosphonates, it's essential to weigh the benefits of continued treatment against potential rare but serious side effects like atypical femur fractures and osteonecrosis of the jaw, which increase with longer treatment duration 1.
Key Considerations
- The decision to take a drug holiday should be individualized based on the patient's fracture risk assessment, taking into account baseline risk for fractures, type of medication, and its half-life in bone, benefits, and harms 1.
- 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, but there is increased risk for long-term harms 1.
- 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 1.
- Bisphosphonate therapy should be restarted if bone mineral density significantly decreases during the holiday, if the patient experiences a fracture, or if fracture risk increases due to new risk factors.
Monitoring and Restarting Therapy
- Regular monitoring during the holiday period is essential, typically including bone density scans every 1-2 years and reassessment of fracture risk factors.
- The patient's treatment plan should be reassessed regularly, considering factors such as age, comorbidities, and concomitant medications, to minimize the risk of adverse events and optimize treatment outcomes 1.
From the Research
Guidance for Taking a Drug Holiday from Bisphosphonates
- The decision to take a drug holiday from bisphosphonates should be individualized, considering factors such as bone mineral density, fracture history, and overall risk of fracture 2, 3, 4.
- Patients with low to moderate risk of fracture may be considered for a drug holiday after 3-5 years of bisphosphonate treatment, while those with high risk should continue treatment without a holiday 2, 3.
- The duration of a drug holiday is not well established, but studies suggest 2-5 years may be appropriate, depending on the type of bisphosphonate used and individual patient factors 3, 4, 5.
Evaluation During a Drug Holiday
- Regular reassessment of bone mineral density and fracture risk is recommended every 1-3 years during a drug holiday 2, 5.
- Patients should be monitored for increases in bone turnover markers and reductions in bone mineral density, which may indicate a need to restart treatment 6.
- Risk factors for holiday-related fractures, such as older age, low hip BMD, and prevalent/incident fractures, should be taken into account when deciding whether to extend or end a drug holiday 6.
Restarting Treatment After a Drug Holiday
- If assessments during a drug holiday show an increased risk of fracture, treatment may be restarted or an alternative therapy, such as raloxifane, teriparatide, or denosumab, may be considered 2, 3.
- The decision to restart treatment should be based on individual patient factors and the results of regular monitoring during the drug holiday 3, 4.