Can Fosamax Be Started During Active Fracture Healing?
Yes, Fosamax (alendronate) can and should be started in this elderly female patient with osteoporosis and a recent lumbar spine fracture, even though the fracture is still healing at 4 months. There is no contraindication to initiating bisphosphonate therapy during fracture healing, and delaying treatment exposes her to continued high fracture risk.
Why Treatment Should Not Be Delayed
Bisphosphonates do not impair fracture healing or bone quality. Histomorphometric analyses demonstrate that alendronate produces normal bone mineralization and structure, supporting normal bone formation during therapy 1, 2.
This patient is at very high fracture risk given her age, established osteoporosis, and recent vertebral fracture—precisely the population that benefits most from immediate bisphosphonate initiation 3, 4.
Fracture risk reduction occurs rapidly with bisphosphonates. Clinical vertebral fracture risk is reduced after just 6-12 months of treatment, making early initiation critical 5.
Evidence Supporting Treatment Initiation
The FDA label for alendronate demonstrates sustained increases in bone mineral density and fracture risk reduction in postmenopausal women with osteoporosis, with no mention of contraindications related to recent fractures 1.
Alendronate reduces vertebral fracture risk by 47-56% in postmenopausal women with existing vertebral fractures, the exact population this patient represents 6.
Bone histology studies in patients treated with alendronate for up to 3 years revealed normal mineralization and structure, confirming that bone formed during therapy is of normal quality 1.
Recommended Treatment Approach
Start alendronate 70 mg once weekly immediately, as this is the standard first-line therapy for postmenopausal women at high fracture risk 3, 4.
Ensure proper administration: Take with a full glass of water (6-8 ounces) on an empty stomach, remain upright for at least 30 minutes, and avoid food/drink during this period to minimize esophageal risk 1, 4.
Provide adequate supplementation: Calcium 1,000-1,200 mg/day and vitamin D 800-1,000 IU/day (target 25(OH)D levels >32 ng/mL) 3, 4.
Correct vitamin D deficiency before starting therapy, as deficiency attenuates efficacy and increases hypocalcemia risk, particularly important before IV bisphosphonate administration 4.
Monitoring Strategy
Perform DXA scan of lumbar spine and total hip at baseline, then repeat BMD measurement 1-2 years after starting therapy to assess response 4.
Monitor for new fractures clinically and reassess fracture risk regularly 4.
Complete any necessary dental work before initiating therapy to reduce osteonecrosis of the jaw risk, though this is extremely rare at <1 case per 100,000 person-years with osteoporosis dosing 4, 7.
Expected Outcomes
Lumbar spine BMD typically increases by 5-8% over 2-3 years with oral alendronate 4.
Total hip BMD increases by 2-5% over the same period 4.
Bone mineral density increases are evident as early as 3 months and continue throughout treatment 1.
Treatment Duration
Standard treatment duration is 5 years for alendronate, after which fracture risk should be reassessed 4, 7, 8.
Patients with previous vertebral fractures (like this patient) may benefit from continuation beyond 5 years, though this decision should be made based on ongoing fracture risk assessment 8.
Critical Pitfall to Avoid
- Do not delay bisphosphonate initiation waiting for "complete fracture healing." There is no evidence that bisphosphonates impair healing, and the 4-month timeframe already represents substantial healing progress. The greater risk is leaving this high-risk patient untreated and vulnerable to additional fractures 1, 2, 6.