Consider Bisphosphonate Holiday After 5 Years

Abstract

Bruce Jancin is with the Denver bureau of Elsevier Global Medical News. ESTES PARK, COLO. — Many bone disease experts are recommending a 1- to 2-year bisphosphonate holiday after 5 years of treatment in response to a recent spate of reports of atypical fractures of the femoral diaphysis. There are now more than 70 reports of such fractures of the femoral shaft occurring in patients on bisphosphonates for longer than 5 years. Affected individuals have also had severely suppressed bone turnover markers, Michael T. McDermott, MD, said at a conference sponsored by the University of Colorado. “This tells us that drugs that turn off a major process like bone remodeling may be very valuable for 3–5 years, but we have to ask, are they good for longer periods of time? We don't know the answer yet,” observed Dr. McDermott, professor of medicine and director of diabetes practice at University of Colorado Hospital, Aurora. These distinctive fractures have been bilateral in two-thirds of cases. There is no associated history of trauma. Radio-graphically they look like nonhealing stress fractures through the bone shaft. Dr. McDermott said he has informally polled many other bone experts across the country. Their consensus: A bisphosphonate holiday for 1–2 years is reasonable after 5 years of therapy in low-risk patients (individuals with a current T score greater than −2.5 and no history of fractures). “Treatment holidays are not advised for high-risk patients,” he stressed. For such patients—those who have a T score less than −2.5 and/or previous fractures—options include a switch to an anabolic agent such as teriparatide (Forteo) or to a nonbisphosphonate antiresorptive agent such as raloxifene (Evista), estrogen, or calcitonin. Continuing the bisphosphonate in a high-risk patient is also a reasonable strategy. “We truly have no data yet as to whether we should stop our medications or not,” the physician noted. Regardless, it's now doubly important to monitor bone mineral density and/or bone turnover biomarkers regularly in patients on long-term bisphosphonates, Dr. McDermott emphasized.