How long patients should take bisphosphonates
As a clinical pharmacist, you will hear more controversy about how long patients should take bisphosphonates (alendronate, etc) for osteoporosis. Many patients get put on a bisphosphonate to prevent fractures and are left on them indefinitely. But long-term use may be associated with problems, jaw osteonecrosis and atypical femur fractures.
Bisphosphonates persist in the bone for years and may continue to prevent fractures even after they're stopped. For example, women who stop alendronate after 5 years have a similar risk of nonvertebral fractures as those who continue it for 10 years. And stopping zoledronic acid (Aclasta) after 3 years prevents fractures almost as well as when it's given for 6 years. Suggest stopping the bisphosphonate after 3 to 5 years for most patients. Suggest continuing it or switching to another osteoporosis medication for patients at high fracture risk, such as those with a recent fracture, on chronic corticosteroids, or if bone density continues to drop.
Explain to patients that prescribers will likely check bone density or bone turnover markers 2 to 3 years after stopping a bisphosphonate. If these indicate bone loss, they'll restart the bisphosphonate, or start raloxifene, calcitonin, Forteo, or Prolia. Continue to encourage patients to get about 1200 mg/day of elemental calcium, and 800 to 2000 units/day of vitamin D. You can get our notes, "Approach to osteoporosis" AND "Management of osteoporosis when patients don't get enough benefit from a bisphosphonate", to help you MANAGE your patients.
References
- Whitaker M, Guo J, Kehoe T, Benson G. Bisphosphonates for osteoporosis--where do we go from here? N Engl J Med. 2012 May 31;366(22):2048-51.
- Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006 Dec 27;296(24):2927-38.
