ASBMR Guidance on Bisphosphonate Use Save
The American Society of Bone and Mineral Research (ASBMR) Task Force has issued a guidance report on the use of bisphosphonates (BP) with a focus on the risk vs. benefits of such therapy. (Citation source http://buff.ly/1Nn0CVb)
Based on data from the FLEX and HORIZON trials, they suggests women at high risk (for example, older women, those with a low hip T-score or high fracture risk score, those with previous major osteoporotic fracture, or who fracture on therapy) should continue BP treatment for up to 10 years (oral) or 6 years (intravenous), with periodic evaluation. The former includes continued reduction in the risk of vertebral fractures, and the latter, rarely, osteonecrosis (localized bone death) of the jaw and unusual fractures of the femur (thigh bone).
The risk of atypical femoral fracture, but not osteonecrosis of the jaw, clearly increases with BP therapy duration, but such rare events are outweighed by vertebral fracture risk reduction in high-risk patients.
In women who are not at high risk after 5 years of oral bisphosphonates or 3 years of intravenous bisphosphonates, clinicians should reassess the drugs' potential benefits and risks and a drug holiday of 2 to 3 years can be considered.
There are limitations to the available data and what is available only applies to vertebral fracture reduction, mostly in white postmenopausal women, and does not replace clinical judgment. Whether such guidance is applicable to men or those with glucocorticoid-induced osteoporosis is unclear and may require some adaptation.
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When we treat postmenopausal women with osteoporosis we are treating elderly patients with multiple comorbid problems and a finite lifespan. For instance , many of these patients have gastric problems and difficulty with ingesting pills. Many of these patients are on polypharmacy and do not want additional pills. Thus, the treatment of these patients frequently depends on factors outside of their DEXA scores or Frax scores, such as their insurance coverage and the patients ability to tolerated additional pills with hypothetical benefit.
JL. So true. Beyond "guidelines", our choice of therapy is either mandated or swayed by those realities of finance and comorbidities. I usually cannot answer the question "what's your favorite or next best drug?" because the choices are often made for me by the factors you indicate.
HI Jack - I agree the E/M visit, DXA and FRAX scores are important. Fortunately we have injectables like denosumab and new ones underinvestigation. I have a main problem with generic bisphosphonates because of data on their tolerability and since no generic is ever investigated in patients before it comes to market I have concern about their efficacy
Im not aware of any good data on the inferiority or intolerability of generic bisphosphonates. I hear such complaints from patients and originator companies, but Im a supporter of cheaper generics for those who need them.
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