Does the patient's previous history of multiple fractures and anti-resorption therapy factor into the recent treatment recommendations?

Does Patient History of Multiple Fractures and Prior Anti-Resorptive Therapy Factor Into Treatment Recommendations?

Yes, a history of multiple fractures and prior anti-resorptive therapy fundamentally changes treatment recommendations by placing the patient in a "very high fracture risk" category, which mandates more aggressive therapy and eliminates eligibility for drug holidays.

Risk Stratification Based on Fracture History

Your patient's history of multiple fractures automatically categorizes them as very high fracture risk regardless of other factors 1:

• Multiple fractures is explicitly listed as a defining criterion for very high fracture risk by the American Association of Clinical Endocrinology, North American Menopause Society, and Society of Obstetricians and Gynaecologists of Canada 1
• Fractures occurring while on anti-resorptive therapy (if applicable to your patient) further elevates risk and indicates treatment failure 1
• The number, location, and recency of prior fractures all independently predict future fracture risk, with associations strongest in men and younger individuals 2

Impact on Bisphosphonate Drug Holiday Decisions

Patients with multiple fractures are NOT candidates for bisphosphonate drug holidays 3:

• After 5 years of bisphosphonate therapy, only patients with no previous hip or vertebral fractures and hip BMD T-score > -2.5 may be considered for a drug holiday 3
• Patients with multiple non-spine fractures should continue treatment beyond 5 years rather than taking a holiday 3
• The American College of Physicians explicitly states that clinicians should continue bisphosphonates after 5 years in patients without strong indication for treatment continuation, but multiple fractures represents precisely such a strong indication 1, 3

Treatment Selection After Prior Anti-Resorptive Therapy

The history of prior anti-resorptive therapy combined with multiple fractures suggests either:

Option 1: Treatment Failure Requiring Escalation

If fractures occurred ≥18 months after beginning bisphosphonate treatment or there was significant BMD decline (≥10%/year) 1:

• Switch to anabolic therapy (teriparatide or romosozumab) rather than continuing oral bisphosphonates 1
• Alternatively, switch to IV bisphosphonate if failure was due to poor absorption or adherence 1
• After anabolic therapy completion, mandatory sequential anti-resorptive therapy must follow to prevent rebound fractures 4, 1

Option 2: Continuing High Risk Despite Adequate Therapy

If the patient completed 5 years of bisphosphonates but remains at very high risk due to multiple fractures 3:

• Continue active osteoporosis treatment beyond 5 years rather than stopping at calcium/vitamin D alone 3
• Treatment options include: continuing oral bisphosphonate for 7-10 years total, switching to IV bisphosphonate, or switching to denosumab or anabolic agents 3
• The American College of Rheumatology conditionally recommends anabolic agents over antiresorptive agents for very high-risk patients with multiple vertebral fractures 3

Critical Consideration: Denosumab Discontinuation Risk

If your patient previously received denosumab (not just bisphosphonates), this creates additional complexity 5, 6:

• Multiple vertebral fractures have been reported following denosumab discontinuation due to rebound increase in bone resorption 5, 6
• Patients with prior fractures are at particularly high risk for rebound fractures after stopping denosumab 6
• If denosumab must be discontinued, bisphosphonate therapy must be initiated within 6 months to suppress rebound osteolysis 3, 6
• Never discontinue denosumab without transitioning to another antiresorptive 3, 6

Monitoring and Ongoing Management

For patients with multiple fractures on continued anti-resorptive therapy 1, 3:

• Do NOT perform routine BMD monitoring during the initial 5-year treatment period, as fracture reduction occurs even without BMD increases 3
• Reassess fracture risk regularly based on new fractures, changes in risk profile, and clinical factors rather than BMD alone 3
• Ensure adequate calcium (1000 mg/day) and vitamin D (800 IU/day) supplementation throughout treatment 1, 5
• Complete any necessary dental work before continuing bisphosphonates or denosumab to reduce osteonecrosis of the jaw risk 3

Common Pitfalls to Avoid

• Do not automatically stop bisphosphonates at 5 years in patients with multiple fractures—this population requires continued treatment 3
• Do not switch to denosumab without a plan for lifelong therapy or eventual transition, as stopping denosumab without sequential bisphosphonate causes dangerous rebound 3, 6
• Do not ignore the temporal relationship between prior anti-resorptive therapy and fracture occurrence—fractures during treatment indicate failure requiring escalation 1
• Do not use BMD changes alone to guide decisions in patients with multiple fractures, as clinical fracture history supersedes BMD in risk stratification 1, 3