Should I continue alendronate (Fosamax) in an 88‑year‑old patient after recent patellar fracture repair surgery?

Continue Alendronate After Patellar Fracture in 88-Year-Old

Yes, continue Fosamax (alendronate) in this 88-year-old patient who just sustained a patellar fracture—this fragility fracture confirms she remains at very high ongoing fracture risk and requires continued pharmacologic treatment to prevent subsequent fractures, particularly hip and vertebral fractures which carry substantial morbidity and mortality at this age. 1

Why This Patient Requires Continued Treatment

The Patellar Fracture Signals High Fracture Risk

• A new fracture occurring during bisphosphonate therapy is a high-risk feature that mandates continuation of treatment beyond the standard 5-year duration. 2
• At age 88, this patient has multiple high-risk features: advanced age (>80 years), recent fragility fracture during treatment, and likely multiple additional risk factors. 2
• The primary goal after any fragility fracture is to prevent subsequent fractures, which occur at dramatically higher rates in the first 1-2 years following the initial fracture. 1

Age 88 Is an Independent High-Risk Factor

• Patients over age 80 should continue bisphosphonate therapy rather than take a drug holiday, as their fracture risk remains elevated regardless of treatment duration. 2
• The risk-benefit calculation at this age strongly favors continued treatment—hip and vertebral fractures in octogenarians carry 20-30% one-year mortality rates, far exceeding the rare risks of osteonecrosis of the jaw (<1 per 100,000 person-years) or atypical femoral fractures (3-9.8 per 100,000 person-years). 2

Practical Management Considerations

Ensure Adequate Calcium and Vitamin D

• Verify the patient is receiving calcium 1000-1200 mg/day and vitamin D 800 IU/day, as these are essential for bisphosphonate efficacy and fracture prevention. 1, 2
• Vitamin D deficiency is endemic in elderly patients and must be corrected to optimize treatment response. 1

Verify Proper Medication Administration

• Confirm the patient (or caregiver) is taking alendronate correctly: with a full glass of water (6-8 ounces), remaining upright for at least 30 minutes, and avoiding food/drink during this period. 2
• Improper administration is a common cause of treatment failure and increased gastrointestinal adverse events. 2

Consider Alternative Formulations If Needed

• If the patient has difficulty with oral administration post-surgery (due to mobility limitations, cognitive issues, or caregiver burden), consider switching to intravenous zoledronic acid (annual infusion) or subcutaneous denosumab (every 6 months) rather than discontinuing treatment. 1
• For patients with dementia, malabsorption, or non-compliance, these parenteral options ensure treatment adherence. 1

Critical Pitfalls to Avoid

Never Discontinue Without Reassessment

• Do not automatically stop bisphosphonates after 5 years in patients who sustain new fractures—this signals ongoing high fracture risk requiring continued treatment. 2
• The FLEX trial showed that patients who discontinued alendronate after 5 years had increased vertebral fractures (5.3% vs 2.4%), and this patient's new fracture demonstrates she is in the high-risk group. 2

Dental Considerations Are Minimal at This Stage

• For routine dental care or extractions in patients on osteoporosis-dose oral alendronate, continuation of therapy is appropriate—the MRONJ risk is extremely low (<1 per 100,000 person-years). 2
• Only consider temporary discontinuation (2-3 months) if extensive dento-alveolar surgery is planned, the patient has active dental infection, or concurrent glucocorticoid use >7.5 mg prednisone daily. 2

Avoid Switching to Denosumab Without Specific Indication

• Do not switch to denosumab unless there is renal impairment (CrCl <60 mL/min), gastrointestinal intolerance, or documented treatment failure on bisphosphonates. 2
• If denosumab is ever started and must be discontinued, bisphosphonate therapy must be initiated within 6 months to prevent catastrophic rebound vertebral fractures. 2

Monitoring During Continued Treatment

Clinical Surveillance, Not Routine BMD Testing

• Do not perform routine BMD monitoring during continued treatment—fracture reduction occurs even without BMD increases, and clinical assessment for new fractures is more relevant. 2
• Monitor clinically for new fractures, changes in mobility, and falls risk every 6-12 months. 2

Duration of Extended Treatment

• Continue alendronate for at least 2-3 additional years beyond the initial 5-year period in this very high-risk patient, then reassess fracture risk again. 2
• Evidence shows that extending treatment beyond 5 years reduces vertebral fractures (though not other fracture types), and the benefits outweigh risks in patients with ongoing high fracture risk like this 88-year-old. 2