When is a drug holiday from Risedronate (bisphosphonate) recommended?

When to Take a Drug Holiday from Risedronate

Consider stopping risedronate after 5 years of treatment in patients without high fracture risk, as evidence shows limited benefit beyond vertebral fracture reduction while long-term harms increase. 1, 2

Standard Treatment Duration

• Treat for 5 years as the standard duration before considering discontinuation, as this represents the evidence-based treatment period where benefits clearly outweigh risks 1, 2
• Risedronate has a shorter half-life than alendronate, resulting in less durable antifracture effects after discontinuation 3, 4
• Evidence suggests a 1-2 year drug holiday duration for risedronate specifically, which is shorter than the 3-5 years recommended for alendronate due to its faster offset of antiresorptive effect 5, 3

Patient Selection for Drug Holiday

Eligible for Drug Holiday (Lower Risk):

• No hip or vertebral fractures before or during treatment 2, 5
• Hip BMD T-score > -2.5 after treatment 2, 5
• No multiple non-spine fractures 2
• Not on chronic glucocorticoid therapy 2
• Age < 80 years 2, 3

Continue Treatment Beyond 5 Years (Higher Risk):

• Previous hip or vertebral fractures during treatment 2, 5
• Hip BMD T-score ≤ -2.5 despite treatment 2, 5
• Multiple non-spine fractures 2
• Age > 80 years 2, 3
• Ongoing glucocorticoid use 2
• Low medication adherence history 3
• Underweight status 3

Monitoring During Drug Holiday

• Do NOT perform routine BMD monitoring during the initial 5-year treatment period, as fracture reduction occurs even without BMD increases 2
• During the drug holiday, reassess patients regularly for new fractures and changes in fracture risk profile 2, 5
• Monitor femoral neck BMD changes, as bone turnover markers increase and BMD decreases during holidays 3
• Resume risedronate if:
  • A new fracture occurs during the holiday 2, 5
  • Fracture risk increases significantly 2
  • Femoral neck T-score remains ≤ -2.5 5

Critical Warnings

• Risedronate drug holidays carry higher fracture risk than alendronate holidays due to faster offset of antiresorptive effect—hip fracture rates are 18% higher with risedronate holidays (HR 1.18,95% CI 1.04-1.34) 4
• Resurgent bone turnover can cause fractures as early as 12 months following risedronate discontinuation in high-risk patients 3
• Never substitute denosumab during a risedronate holiday, as denosumab discontinuation causes rebound fractures and requires immediate bisphosphonate initiation within 6 months 2, 5
• Complete all dental work before resuming risedronate to reduce osteonecrosis of the jaw risk 2

Special Considerations

• Patients initially treated with anabolic agents (teriparatide, romosozumab) must receive an antiresorptive agent after discontinuation to prevent serious rebound vertebral fractures—never allow a drug holiday in this scenario 1, 2
• In patients with renal impairment (creatinine clearance < 60 mL/min), consider switching to denosumab rather than continuing risedronate, though this requires lifelong commitment without holidays 2