From the Guidelines
A bone holiday should be considered after 3-5 years of bisphosphonate therapy for moderate-risk patients or 5-10 years for high-risk patients, based on individualized assessment of fracture risk, including bone mineral density measurements and fracture history, as recommended by the American College of Physicians 1.
Key Considerations
- The decision to take a bone holiday should be individualized, taking into account the patient's baseline risk for fractures, type of medication, and its half-life in bone, as well as benefits and harms 1.
- Patients at high risk, such as those with previous hip or spine fractures, T-score below -2.5, or multiple risk factors, may need to continue therapy longer before a holiday 1.
- For bisphosphonates, the holiday typically lasts 1-2 years with monitoring, while denosumab should not be stopped without transitioning to another therapy due to rebound fracture risk 1.
Management During Bone Holiday
- Patients should maintain calcium intake (1000-1200mg daily) and vitamin D (800-1000 IU daily) during the holiday 1.
- Weight-bearing exercise and periodic bone density testing are also recommended during this period 1.
Rationale for Bone Holidays
- Bisphosphonates accumulate in bone and provide residual protection, but long-term treatment increases the risk of rare side effects like atypical femur fractures and osteonecrosis of the jaw 1.
- The goal of a bone holiday is to balance the benefits of bisphosphonate therapy against the potential risks, while maintaining bone health and preventing fractures 1.
From the FDA Drug Label
- 4 Osteonecrosis of the Jaw ... For patients requiring invasive dental procedures, discontinuation of bisphosphonate treatment may reduce the risk for ONJ ... Discontinuation of bisphosphonate therapy should be considered based on individual benefit/risk assessment.
- 5 Atypical Subtrochanteric and Diaphyseal Femoral Fractures ... Interruption of bisphosphonate therapy should be considered, pending a risk/benefit assessment, on an individual basis.
Consider a bone holiday in the following situations:
- Before invasive dental procedures to reduce the risk of osteonecrosis of the jaw
- In patients with atypical subtrochanteric and diaphyseal femoral fractures, pending a risk/benefit assessment on an individual basis 2
From the Research
Considerations for a Bone Holiday
When considering a bone holiday, several factors should be taken into account, including the duration of bisphosphonate therapy, the type of bisphosphonate used, bone mineral density, and patient risk factors 3, 4, 5.
- Patients without previous hip, vertebral, or multiple non-spine fractures who are successfully treated with oral bisphosphonates for 5 years (3 years if intravenous) may be offered a 3-5 year drug holiday, particularly if hip BMD T-score is > -2.5 3.
- A review of the literature suggests that a therapeutic pause after 3-5 years of bisphosphonate treatment may be considered in patients with minor bone deficiencies and no recent fragility fracture (low risk) and in patients with moderate bone deficiencies and/or recent fragility fracture (moderate risk) 4.
- The duration and length of a drug holiday should be individualized for each patient, with evaluation based on serial bone mass measurements, bone turnover rates, and fracture history evaluation 4, 6.
Patient Risk Factors
Patient risk factors, such as age, sex, and body weight, may also influence the decision to initiate a bone holiday 5.
- Elderly patients and those with very low BMD warrant close follow-up during a drug holiday 6.
- A fracture, early significant rise in bone turnover markers, and/or a decline in BMD should warrant resumption of osteoporosis therapy 6.
Duration of Bisphosphonate Therapy
The duration of bisphosphonate therapy is also an important consideration when deciding whether to initiate a bone holiday.
- Bisphosphonates should only be continued beyond 10 years (6 years if parenteral) in patients at very high risk of fracture 3.
- A systematic review and meta-analysis found that bisphosphonate discontinuation may be considered for women who do not have low hip BMD after 3-5 years of initial treatment, while women who have low hip BMD may benefit from treatment continuation 7.