“Bisphosphonate Holiday” 2014

“You are entering a Data-Free Zone”   That was unfortunately the messasge at the joint meeting of the International Society for Clinical Densitometry (ISCD) and the International Osteoporosis Foundation (IOF) last month.  We simply do not have data from a study involving tens of thousands of patients.  We do know some things that are helpful.

Bisphosphonates build up in bone over time.  After about 5 years of Bisphosphonate therapy, you should have enough medication in your bones to last for additional years.  How many years?  That depends.  Different individuals lose Bisphosphonates from their bones at different rates.  Different Bisphosphonates tend to stay in bone longer or shorter than others.  We call the time you are able to stop taking medication for a while (because you have enough in your bones already) “Bisphosphonate Holiday”.

Zolendronate (Reclast and Zometa) and Alendronate (Fosamax) persist in bone the longest.  Risendronate (Actonel) persists the shortest time.  Ibandronate (Boniva) persists somewhat longer than Risendronate.  The persistance of these medications in your bones determines the length of “holiday” you can safely take.

Individuals vary  in how fast their bone is resorbed and replaced naturally.  The faster your natural “bone turnover”, the faster you will lose Bisphosphonates from your bone.  Also, the faster you lose calcium (BMD) and bone matrix (Protein part of bone), and the higher your Fracture Risk without treatment.

“Bisphosphonate Holiday” exists because we know that increased risk of OsteoNecrosis of the Jaw (ONJ), and of Atypical Fracture of the Femur (AFF), starts after about 8 to 10 years of Bisphosphonate treatment in most individuals.  Very,very few individuals develop these “complications” sooner, and most of those are on the much higher doses used in cancer patients.  Some individuals develop these “complications” without ever having had a single dose of  Bisphosphonate or Denosumab (Prolia).  ONJ and AFF are also “complications” of Untreated Osteoporosis.

Denosumab (Prolia) has a built in “holiday” in month 6 because it does NOT build up in bone.

Teriparatide (Forteo) is totally different.  Many osteoporosis experts use Forteo to TREAT both ONJ and AFF.

We discuss the concept of “Bisphosphonate Holiday” carefully with our patients who are on Bisphosphonates.  Each patient is different.  We try to match our treatment with each patient.

What was the message at the meeting?  Use general Guidelines as guidelines, but treat patients as Individuals.  I learned that over 40 years ago.

Jay Ginther, MD

Categorised in: Medications