Should a patient be discontinued from alendronate (bisphosphonate) if their bone density has improved to osteopenia?

From the Guidelines

Patients with improved bone density from osteoporosis to osteopenia should consider discontinuing alendronate after 3-5 years of treatment, unless they have a strong indication for continued therapy, such as a high risk of fractures. This approach is supported by the American College of Physicians' living clinical guideline, which suggests that increasing the duration of bisphosphonate therapy beyond 3 to 5 years reduces the risk of new vertebral fractures but not other fractures, while also increasing the risk of long-term harms 1. Key considerations for discontinuation include:

• The patient's individualized fracture risk assessment, taking into account bone density, history of fractures, and multiple risk factors for fractures
• The potential benefits of minimizing rare adverse effects associated with long-term bisphosphonate use, such as atypical femur fractures and osteonecrosis of the jaw
• The importance of continued monitoring of bone mineral density every 1-2 years and restarting treatment if significant bone loss occurs or fracture risk increases
• The need for patients to maintain healthy lifestyle modifications, including calcium and vitamin D supplementation, weight-bearing exercise, and fall prevention strategies, even during a drug holiday 1.

From the FDA Drug Label

In placebo-controlled clinical studies of alendronate sodium, the percentages of patients with these symptoms were similar in the alendronate sodium and placebo groups. The FDA drug label does not answer the question.

From the Research

Discontinuation of Alendronate in Osteopenia Patients

• The decision to discontinue alendronate in patients with osteopenia should be based on individual patient factors, including the severity of osteopenia and the presence of other risk factors for fracture 2.
• There is no clear consensus on when to discontinue alendronate in patients with osteopenia, but some studies suggest that treatment can be discontinued after a certain period of time, such as 5-10 years, depending on the patient's response to treatment and the presence of other risk factors 2.
• A cost-effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women with osteopenia found that alendronate was most cost-effective in women with borderline osteoporosis (t scores of -1.5 and -2) 3.

Effects of Alendronate on Bone Mineral Density

• Alendronate has been shown to increase bone mineral density (BMD) in patients with osteopenia, which can reduce the risk of fracture 4, 5.
• A study found that the combination of alendronate with alfacalcidol and calcium can significantly improve BMD in older patients with osteopenia 4.
• However, another study found that the increase in BMD in response to combination treatment with alendronate plus alfacalcidol was not strongly associated with fracture risk reduction 6.

Considerations for Discontinuation

• The decision to discontinue alendronate in patients with osteopenia should take into account the individual patient's risk factors for fracture, including their BMD, age, and medical history 2, 3.
• Patients with osteopenia who are at high risk of fracture may benefit from continued treatment with alendronate, while those at lower risk may be able to discontinue treatment after a certain period of time 2, 3.
• Further research is needed to determine the optimal duration of alendronate treatment in patients with osteopenia and to identify the factors that predict the risk of fracture in these patients 2, 6.