What is the recommended duration of Fosamax (alendronate) therapy after initiating steroid treatment?

From the Guidelines

You should continue Fosamax treatment for as long as you are on steroid therapy and for at least 1-2 years after stopping steroids, with regular bone density scans every 1-2 years to monitor your response to treatment, as recommended by the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1.

Key Considerations

• The duration of Fosamax treatment depends on individual risk factors for bone loss and fractures, which should be assessed using the Fracture Risk Assessment Tool (FRAX) with glucocorticoid (GC) adjustment 1.
• Steroids can rapidly cause bone loss, particularly in the first 3-6 months of treatment, and Fosamax helps prevent this by inhibiting bone breakdown.
• Regular bone density scans (typically every 1-2 years) are important to monitor your response to treatment and adjust the treatment strategy as needed 1.
• The recommended treatment strategy for adults ≥40 years at moderate, high, or very high risk of fracture includes optimized intake of dietary and supplemental calcium and vitamin D, as well as bisphosphonate (BP) treatment, such as Fosamax 1.

Treatment Recommendations

• The standard dose of Fosamax is 70mg once weekly or 10mg daily.
• Calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplements are also typically recommended alongside Fosamax.
• Common side effects of Fosamax include heartburn and esophageal irritation, so it is essential to take the medication with a full glass of water first thing in the morning and remain upright for at least 30 minutes afterward.

Monitoring and Follow-up

• Regular follow-up risk assessments during GC treatment are crucial to monitor the effectiveness of Fosamax treatment and adjust the treatment strategy as needed 1.
• BMD with VFA or spinal x-ray every 1-2 years during OP therapy and after OP therapy is discontinued is recommended to monitor the response to treatment 1.

From the FDA Drug Label

1.6 Important Limitations of Use 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.

The duration of alendronate sodium therapy for patients starting on steroids is not explicitly stated in the label. However, for patients with glucocorticoid-induced osteoporosis, the label mentions that the safety and effectiveness of alendronate sodium are based on clinical data of up to two years' duration 2.

• The label suggests that patients at low-risk for fracture should be considered for drug discontinuation after 3 to 5 years of use.
• It is recommended that all patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis.
• The optimal duration of use has not been determined, and the decision to continue or discontinue therapy should be based on individual benefit/risk assessment.

From the Research

Duration of Fosamax Treatment with Steroids

The ideal duration of Fosamax (alendronate) treatment in patients taking steroids is not explicitly stated in the provided studies. However, the following points can be considered:

• A study published in 2016 3 found that bisphosphonates, including Fosamax, are beneficial in reducing the risk of vertebral fractures and preventing steroid-induced bone loss, with high-certainty evidence extending to 24 months of use.
• Another study from 2021 4 compared the effects of denosumab and bisphosphonates after teriparatide treatment and found that denosumab yielded higher additional lumbar spine bone mineral density (BMD) gain on average compared to bisphosphonates after 12 months.
• A 2023 systematic review and meta-analysis 5 found that teriparatide and denosumab were superior to bisphosphonates in increasing lumbar vertebrae BMD, and teriparatide was superior in preventing vertebral fractures and increasing hip BMD.
• A 2024 systematic review 6 compared the effectiveness of teriparatide and alendronate in postmenopausal osteoporosis and found that teriparatide was more effective in increasing BMD of L2-4 vertebrae and hip bone, with a lower incidence rate of morphometric vertebral fracture and better quality of life.
• A 2021 retrospective cohort study 7 found that denosumab and zoledronic acid may be as effective as teriparatide for hip fracture prevention in frail older adults.

Key Considerations

• The duration of Fosamax treatment may depend on individual patient factors, such as the severity of osteoporosis, steroid dose, and response to treatment.
• Bisphosphonates, including Fosamax, have been shown to be effective in reducing the risk of vertebral fractures and preventing steroid-induced bone loss, but the optimal treatment duration is not well established.
• Other treatments, such as denosumab and teriparatide, may be considered as alternatives or sequential therapy to bisphosphonates, depending on patient characteristics and response to treatment.

Some key points to consider when determining the duration of Fosamax treatment with steroids include:

• The patient's bone mineral density (BMD) and fracture risk
• The dose and duration of steroid treatment
• The patient's response to Fosamax treatment, including changes in BMD and fracture risk
• The potential for adverse effects, such as osteonecrosis of the jaw or atypical femoral fractures
• The availability and potential benefits of alternative treatments, such as denosumab or teriparatide.