Osteoporosis Experts Discuss Bisphosphonate Holidays

Prevention & Treatment

Strategies to reduce AFF risk in patients on bisphosphonates include drug holidays, but rheumatologists may also watch for prodromal pain symptoms, and ask patients about unexplained hip or thigh pain at office visits.^18,13 Imaging, including extended femur DXA scans or single-energy femoral scans, may help identify incipient AFFs.^19,20

Surgical treatments include fixation with intramedullary, full-length nails and fracture augmentation with bone marrow aspirate.^21,22 After surgery, physicians should image the contralateral femur to assess for incomplete fracture on the other side, because bilaterality is so common, Dr. Shane noted.

Dr. Shane said she stops antiresorptive therapy after surgery, and that some physicians prescribe teriparatide after surgery to speed healing. Data from a 2020 study showed 40% of patients with incomplete AFFs progressed while on teriparatide, although patients with complete AFFs seemed to heal faster. However, no evidence has shown teriparatide enhances AFF healing, and in patients with AFFs who are still at high risk for fractures, three to six months of teriparatide may suffice. If patients are on teriparatide for two years, Dr. Shane recommends that physicians monitor bone turnover markers and bone mineral density, and then consider another antiresorptive therapy, such as estrogen, synthetic estrogen receptor modulators, calcitonin, denosumab or bisphosphonates.²³

“While AFFs are definitely related to long-term bisphosphonate use, we are not yet sure that it is causal,” said Dr. Shane. “In my patients’ view, AFFs are not rare. They feel that AFFs are underreported, and to quote one of my patients, ‘the risk is low unless it happens to you.’ As clinicians and scientists, we have to find more effective ways to communicate that osteoporotic fractures have devastating effects on people’s lives. Bisphosphonates and denosumab can reduce these fractures. But we need to listen to patients’ concerns.”

Susan Bernstein is a freelance journalist based in Atlanta.

References

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