From the Guidelines
For someone with osteoporosis who has experienced multiple fragility fractures despite a few years of alendronate treatment, a change in therapy to denosumab (Prolia) 60mg subcutaneously every 6 months is recommended, as it has been shown to reduce the risk of vertebral and nonvertebral fractures 1. This recommendation is based on the most recent and highest quality evidence, which suggests that denosumab is a effective treatment option for patients with osteoporosis who are at high risk of fracture. The patient should also continue to receive supplementation with calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily), as well as engage in regular weight-bearing exercise, fall prevention strategies, and lifestyle modifications (smoking cessation, limiting alcohol). Monitoring should include bone mineral density testing every 1-2 years and periodic assessment of serum calcium, vitamin D levels, and renal function. The occurrence of multiple fractures while on alendronate suggests treatment failure, possibly due to poor absorption, inadequate compliance, or development of resistance to the medication. Other treatment options, such as teriparatide (Forteo) 20mcg subcutaneously daily for up to 2 years or zoledronic acid (Reclast) 5mg IV once yearly, may also be considered, but denosumab is the preferred choice based on the latest evidence 1. It is essential to note that the treatment plan should be individualized, and the patient's preferences, fracture risk profile, and benefits, harms, and costs of medications should be taken into account 1. Regular follow-up and monitoring are crucial to ensure the effectiveness of the treatment plan and to make any necessary adjustments. In addition, the patient's serum total testosterone level should be assessed, and appropriate hormone replacement therapy should be considered if necessary 1. Overall, the goal of treatment is to reduce the risk of future fractures, improve bone density, and enhance the patient's quality of life.
From the FDA Drug Label
The FDA drug label does not answer the question about the treatment for osteoporosis for someone who has had multiple fragility fractures with only a few years treatment on alendronate.
From the Research
Treatment Options for Osteoporosis with Multiple Fragility Fractures
- For patients with severe osteoporosis and high fracture risk, bisphosphonates alone are unlikely to provide long-term protection against fracture and restore bone mineral density (BMD) 2
- Sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, may provide better long-term fracture prevention 2
- Teriparatide has been shown to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 2
- The sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 2
Considerations for Patients on Alendronate
- The use of bisphosphonates, such as alendronate, has been limited to up to 10 years with oral bisphosphonates due to the risk of rare side-effects 2
- Reappraisal of ongoing use of bisphosphonates after about 5 years is endorsed by expert consensus, and 'drug holidays' should be considered at this time 3
- Observational data suggest that the incidence of atypical femoral fractures increases steeply with duration of bisphosphonate use, resulting in concern that the benefit-risk balance may become negative in the long term 3
Comparative Effectiveness of Drug Treatments
- Teriparatide, bisphosphonates, and denosumab are most effective in reducing the risk of fragility fractures 4
- Differences in efficacy across drugs are small; therefore, patients and clinicians need to consider their associated harms and costs 4
- Calcium and vitamin D are ineffective given separately but reduce the risk of hip fractures if given in combination 4