Wednesday, 17 Oct 2018

You are here

Consensus on OP Drug Holidays

The association of very rare events, like osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF), with bisphosphonate use has changed the long-term management of anti-resorptive therapy.

Bisphosphonates and denosumab have proven efficacy in fracture reduction, but the optimal use and duration remains unclear.  A recent systematic review of the literature has resulted in the following expert opinion consensus: 

  • Extending bisphosphonate treatment beyond 3–5 years does not confer additional benefit in low-risk populations.
  • Treatment re-initiation (usually 1–3 years after bisphosphonate withdrawal) depends on risk factors, new fractures and bone mineral density.
  • The evidence regarding denosumab discontinuation is limited but caution is advised, as there may be a “rebound effect” with regard to fractures.

Discontinuation of bisphosphonates may be considered in all patients who have been on bisphosphonates (alendronate, risedronate or zoledronic acid) for more than five years, But the same cannot be said for ibandronate and denosumab, as the evidence is limited.

If the patient has not experienced fractures before or during therapy and the fracture risk is low, a “drug holiday” can be considered.  

There is no solid evidence for the duration of the drug holiday, but, 1–2 years for risedronate, 3–5 years for alendronate and 3–6 years for zoledronic acid are suggested. After this time, the patient should be reassessed.

Aanti-osteoporotic treatment should be resumed when there is a new fracture or if the fracture risk has increased or BMD remains low (femoral neck T-score ≤−2.5),

In the case of denosumab discontinuation, close monitoring is suggested, due to the possibility of rebound fractures.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Vitamin D Fails to Improve Bone Health

The current edition of Lancet Diabetes & Endocrinology suggests that neither vitamin D supplementation, nor dose, will improve bone density or prevent fractures in adults. (Citation source: https://buff.ly/2O9tqxI)

Zolendronic Acid Benefits Elder Women with Osteopenia

The NEJM reports that zolendronic acid was shown to significantly lower the risk of nonvertebral or vertebral fragility fractures in older women with osteopenia. 

Neuropathic Like Knee Pain

Fernandez and colleagues have shed further light on a significant subset of patients with knee pain - specifically, those with neuropathic like knee pain (NKP) that includes those with knee pain modified by central and peripheral neurologic dysfunction.

Knee Arthroscopic Surgeries on the Decline

A JAMA Internal Medicine report has shown that the rate of arthroscopic surgery has significantly declined, in an era when arthroplasty and the incidence of osteoarthritis (OA) has increased. (Citation source http://bit.ly/2DtpeUp)

Fractures May Lead to Systemic Bone Loss

Researchers at the University of California - Davis have shown that elderly women who had an upper body fracture or multiple fractures had more loss of hip density compared to those who who did not fracture. Systemic bone loss may increase the risk of future fractures.