Duration of Bisphosphonate Treatment for Patients with Osteoporosis: A Review of Clinical Effectiveness and Guidelines

Throughout life bone tissue is constantly formed and resorbed; however, with age this process becomes less effective. Osteoporosis is a bone disease characterised by a deterioration of bone tissue in which bones become progressively less dense and more fragile. When bones are severely weakened by osteoporosis they can fracture easily as a result of minimal trauma (such as falling from standing). Despite overall skeletal fragility, fractures of the wrist, shoulder, vertebrae and hip are those most commonly associated with osteoporosis.,Osteoporosis can affect Canadians of all ages; though, it is more common in those 50 years or older. In this population, it is estimated there were 57,413 hospitalizations for a total of 832,594 days from April 1, 2007 to March 31, 2008, costing $1.181 billion (2010 Canadian dollars) in emergency care, acute care admissions, and same day surgeries. Furthermore, females are disproportionately affected then males., There are many risk factors for osteoporosis, including cigarette smoking, long term use of corticosteroids or other high risk medications, and insufficient dietary intake of calcium and vitamin D., The presence of these, along with findings from a physical examination and laboratory investigations, may prompt further investigation with a bone mineral density (BMD) test using a dual X-ray absorptiometry (DXA) method. A DXA t-score result between −1 and – 2.5 standard deviations indicates low bone mass (osteopenia), while osteoporosis is a t-score at or below –2.5 standard deviations., This report will focus on patients with osteoporosis.The goals of therapy for patients with osteoporosis include the prevention of fractures, prevention of associated disability and loss of independence, as well as the preservation or enhancement of bone mass. There are several pharmacological treatments for established osteoporosis, such as: bone resorption inhibitors, which slow down bone loss (e.g., bisphosphonates [BIS], denosumab, raloxifene, and estrogen), as well as bone formation agents, which stimulate the formation of bone tissue (e.g., teriparatide). This report will focus on the BIS class of pharmaceuticals, which are the mainstay of osteoporosis treatment and include: alendronate (ALN), etidronate (ETN), risedronate (RSN), and zoledronic acid (ZLN).As with any drug therapy, there are adverse effects (AE) associated with BISs and their antifracture benefits ought to be weighed against any possible risks to the patient. Because of concerns about serious AEs, such as osteonecrosis of the jaw (ONJ), atrial fibrillation, and atypical femoral fractures (AFF), there have been suggestions of implementing drug holidays as part of the therapy, where the medication is stopped for a period of time, often several years.,,– However, the optimal duration of therapy before a drug holiday could be considered and the length of the drug holiday (either indefinite or otherwise), is uncertain and remains a clinical controversy.CADTH has previously reviewed the evidence for the use of bisphosphonates.– One report was a list of abstracts based on evidence available in August of 2019, one focused on a different patient population (patients with osteopenia and low risk fractures), and another focused on prevention of osteoporosis in patients treated with systemic corticosteroids. The objective of the current report is to evaluate the clinical evidence and evidence-based guidelines regarding various treatment durations of BISs for the treatment of osteoporosis.

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