When to Consider Stopping Bisphosphonates
Clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation, with the decision based on individualized fracture risk assessment rather than age alone. 1
The 5-Year Decision Point
The critical timeframe for reassessing bisphosphonate therapy is after 5 years of treatment, not at any specific age. 1 This recommendation applies to an 87-year-old patient just as it would to a younger patient—the decision hinges on fracture risk, not chronological age.
Risk-Stratified Approach After 5 Years
High-Risk Patients (Continue Treatment):
- Prior fracture history, especially during treatment 1
- Femoral neck T-score ≤-2.5 despite treatment 2
- New fracture occurrence while on therapy 2
- Significant bone mineral density loss (≥10%/year) 1
- These patients should continue treatment for 7-10 years total 3
Moderate-Risk Patients (Consider Drug Holiday):
- No fractures during treatment and stable BMD 4
- T-score improved to >-2.5 2
- Can consider 1-2 year drug holiday with close monitoring 4
- Requires reassessment every 1-2 years during the holiday 5
Low-Risk Patients (Stop Treatment):
- No fractures before or during therapy 4
- Stable or improved bone mineral density 2
- Can remain off treatment as long as BMD remains stable 5
Why 5 Years Matters More Than Age
The rationale for the 5-year threshold is based on the risk-benefit profile shift:
- Extending treatment beyond 5 years reduces vertebral fractures but NOT other fracture types 3
- Long-term harms increase with duration, particularly osteonecrosis of the jaw and atypical femoral fractures 1, 3
- Bisphosphonates accumulate in bone and provide residual antifracture protection for 1-2 years after discontinuation 5, 6
Drug-Specific Considerations for Holiday Duration
The duration of a safe drug holiday depends on which bisphosphonate was used, not the patient's age:
Alendronate or Zoledronic Acid:
- Longer drug holidays possible: 3-5 years for alendronate, 3-6 years for zoledronic acid 4
- These agents have persistent skeletal effects due to longer bone half-life 6
Risedronate or Ibandronate:
- Shorter drug holidays: 1-2 years for risedronate, up to 6 months for ibandronate 6, 4
- Quick loss of benefits after discontinuation requires closer monitoring 6
Critical Pitfalls to Avoid
Do not simply continue bisphosphonates indefinitely without reassessment after 5 years—this exposes patients to increasing harm without proportional benefit. 1, 3
Do not base the decision solely on age. An 87-year-old with low fracture risk and stable BMD should stop treatment, while an 87-year-old with prior fractures and T-score ≤-2.5 should continue. 1, 2
If treatment failure occurs (fracture after ≥18 months of therapy or ≥10%/year BMD loss), switch to another medication class (teriparatide or denosumab) rather than continuing or switching to another bisphosphonate. 1, 7
Monitoring During and After Discontinuation
During treatment continuation beyond 5 years:
- Monitor BMD every 1-2 years 2
- Maintain oral examination and good oral hygiene to prevent osteonecrosis of the jaw 3
- Complete any invasive dental procedures before continuing therapy 3
During drug holiday:
- Reassess fracture risk annually 4
- Monitor BMD to detect significant decline 2
- Resume treatment if new fracture occurs or fracture risk increases 4
Special Consideration for Glucocorticoid Users
For patients on chronic glucocorticoid therapy who remain at moderate-to-high fracture risk, continue active treatment beyond 5 years (either continuing oral bisphosphonate or switching to IV bisphosphonate or another class). 1 This represents an exception where continued treatment is warranted regardless of age.