From the Guidelines
Bisphosphonate treatment should be re-evaluated after 2 years of therapy, with DEXA scans typically ordered every 1-2 years during treatment and at the time of re-evaluation, as suggested by the American Society of Clinical Oncology clinical practice guideline update 1.
Key Considerations
- The frequency of re-evaluation and DEXA scans may vary depending on the individual patient's risk factors and response to treatment.
- For patients at high fracture risk, treatment may continue for a longer period, up to 5 years, before re-evaluation, as recommended by the American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1.
- During re-evaluation, if significant improvement is noted or fracture risk has decreased, a drug holiday might be considered, particularly for those who have been on alendronate, risedronate, or zoledronic acid.
- The drug holiday duration varies based on the specific bisphosphonate used, with shorter holidays (1-2 years) for risedronate and longer ones (2-3 years) for alendronate or zoledronic acid due to their longer skeletal retention.
Monitoring and Follow-up
- DEXA scans should be performed every 1-2 years to monitor for bone loss during treatment and drug holidays.
- Serum creatinine should be monitored before each dose of pamidronate or zoledronic acid, and serum calcium and vitamin D levels should be evaluated regularly, as recommended by the American Society of Clinical Oncology clinical practice guideline update 1.
- Patients should be educated on the importance of maintaining excellent oral hygiene and avoiding invasive dental procedures to minimize the risk of osteonecrosis of the jaw.
From the FDA Drug Label
The optimal duration of use has not been determined. The safety and effectiveness of alendronate sodium for the treatment of osteoporosis are based on clinical data of four years duration. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis Patients at low-risk for fracture should be considered for drug discontinuation after 3 to 5 years of use. Patients who discontinue therapy should have their risk for fracture re-evaluated periodically.
Bisphosphonate treatment should be re-evaluated periodically. For patients at low-risk for fracture, treatment can be considered for discontinuation after 3 to 5 years of use. After discontinuation, the patient's risk for fracture should be re-evaluated periodically. However, the label does not specify the exact frequency for re-evaluation or the use of DEXA scans 2.
From the Research
Re-Evaluation of Bisphosphonate Treatment
- The frequency of re-evaluating bisphosphonate treatment and ordering DEXA scans depends on the patient's risk of fracture and bone density 3, 4.
- For patients with low to moderate risk of fracture, a bone health reevaluation is recommended every 1-3 years after 3-5 years of bisphosphonate treatment 3.
- Patients with high fracture risk should be maintained on bisphosphonate therapy without a drug holiday, with periodic evaluation 3, 4.
- The American Society for Bone and Mineral Research suggests that after 5 years of oral bisphosphonate or 3 years of intravenous bisphosphonate, reassessment of risk should be considered 4.
Duration of Bisphosphonate Treatment
- The ideal duration of bisphosphonate therapy remains controversial, but studies suggest that treatment can be continued for up to 10 years (oral) or 6 years (intravenous) in high-risk patients, with periodic evaluation 4.
- A drug holiday of 2 to 3 years can be considered for patients not at high fracture risk after 3 to 5 years of bisphosphonate treatment 4.
- The duration and length of drug holiday should be individualized for each patient, based on serial bone mass measurements, bone turnover rates, and fracture history evaluation 3.
DEXA Scans and Bone Density Measurements
- DEXA scans are used to measure bone mineral density (BMD) and assess the risk of fracture 3, 4.
- BMD measurements can help determine the effectiveness of bisphosphonate treatment and guide treatment decisions 5, 6.
- Studies have shown that switching to denosumab or teriparatide after completion of bisphosphonate treatment can lead to improvements in BMD 5, 6.