Drug Insight: choosing a drug treatment strategy for women with osteoporosis-an evidence--based clinical perspective

Risk of long-term infection-related death in clinical osteoporotic vertebral fractures: A hospital-based analysis

Background

Osteoporotic vertebral fractures adversely impact quality of life and also increase the risk of infection and mortality. Alendronate treatment increases bone mass and reduces the risk of fractures in patients with osteoporosis by suppressing bone resorption. We investigated the relationship between alendronate treatment and infection-related death in patients with osteoporotic vertebral fractures.

Methods

We retrospectively reviewed patients with osteoporosis and vertebral fractures from January 2001 to December 2007. The use of alendronate, glucocorticoid and medical factors including smoking, alcohol consumption, diabetes, hypertension, stroke, liver disease, heart disease, and pulmonary disease were analyzed. Cox regression was used to analyze the factors associated with life-threatening infections.

Results

A total of 210 patients (161 females and 49 males) were included with a mean age of 74.06±7.43 years. Among them, 87 had life-threatening infections and 123 did not. In Cox regression analysis, the patients who used alendronate had a significantly lower risk of life-threatening infections (p = 0.006, HR = 0.845, 95% CI 0.750–0.954), while glucocorticoid users had higher risk of death (p = 0.010, HR = 2.037, 95% CI 1.187–3.498).

Conclusions

Osteoporosis was associated with a high rate of life-threatening infections, and the use of alendronate had a lower rate of infection-related death. Therefore, we suggest that alendronate be used after vertebral fractures in these patients.

Compliance and persistence with oral bisphosphonates for the treatment of osteoporosis in female patients with rheumatoid arthritis

Background

Poor adherence with oral bisphosphonates (BPs) can mitigate their therapeutic benefit for osteoporosis and is a significant clinical burden. Most previous studies regarding adherence with oral BPs have focused on postmenopausal osteoporosis, but little attention has been given to patients with rheumatoid arthritis (RA). Thus, we investigated compliance and persistence with oral BPs in the treatment of osteoporosis and analyzed risk factors for poor adherence in female patients with (RA) in real setting.

Methods

This is a retrospective longitudinal study including 396 female patients with RA in whom oral BPs were newly initiated from Aug 2004 to Aug 2014 at a university rheumatology center in South Korea. Compliance was quantified using the 1-year medication possession ratio (MPR), while persistence was defined as duration from the initiation to the end of BPs therapy without interruption exceeding 56 days. Seropositve RA was defined as having a positive test result for the presence of either rheumatoid factor or anti-cyclic citrullinated peptide antibody.

Results

Of 396 RA patients, 221 (55.8%) were prescribed risedronate 35 mg weekly; 17 (4.3%) received alendronate 70 mg weekly; and 158 (39.9%) received ibandronate 150 mg monthly. The 1-year MPR was 70.1% and the proportion of RA patients with the 1-year MPR ≥ 0.8 was 60.1%. A total of 274 (69.2%) patients discontinued oral BPs during the study period and persistence with BPs was 63.3% at 1 year, 50.7% at 2 years and 33.3% at 3 years. The most common cause of non-persistence was adverse events (47.5%), followed by poor health literacy (40.5%) and cost (12%). Both compliance and persistence with monthly oral BPs were significantly lower than those with weekly regimens (OR: 2.48, 95% CI: 1.59–3.89, P < 0.001 and HR: 2.19, 95% CI: 1.69–2.83, P < 0.001, respectively). Additionally, patients with seropositive RA showed better compliance and persistence with BPs compared with their seronegative counterparts.

Conclusions

Compliance and persistence with oral BPs in RA patients were suboptimal in real practice, thereby limiting the efficacy of osteoporosis treatment. Extending the dosing interval of BPs may improve medication adherence in RA patients.

Poor 1st-year adherence to anti-osteoporotic therapy increases the risk of mortality in patients with magnetic resonance imaging-proven acute osteoporotic vertebral fractures

AIM

Anti-osteoporotic therapy requires years of proper compliance to reduce the risk of fractures. This study investigated the effects of 1st-year adherence to anti-osteoporotic treatment on the risk of mortality in patients with magnetic resonance imaging-proven acute osteoporotic vertebral fractures after vertebroplasty.

PATIENTS AND METHODS

This retrospective study included 294 patients (252 females; mean age, 73.93±7.18 years) with osteoporosis and acute vertebral fractures treated with vertebroplasty between January 2001 and December 2007. Sex, age, body mass index, comorbidities, previous hip fracture, number of vertebral fractures, 5-year re-fracture rate, and use of anti-osteoporotic therapy were recorded for each patient. Adherence was determined according to compliance and persistence for 1 year. Compliance was calculated as the medication possession ratio (MPR), and persistence as the time from treatment initiation to discontinuation. Poor adherence was defined as either non-compliance or non-persistence.

RESULTS

The MPR of the patients at 1 year was 55.1%, with a persistence rate of 69.4% and a poor adherence rate of 62.6%. Cox regression analysis revealed that poor adherence to medications was associated with a significantly higher risk of mortality after adjustment for potential confounders (hazard ratio [HR]: 1.75; 95% CI: 1.13-2.71). Poor adherence to medications was significantly associated with an increase in the rate of infection (HR: 4.56; 95% CI: 1.12-18.52), which was the most common cause of death.

CONCLUSION

Poor adherence to anti-osteoporotic therapy significantly increases the risk of morality, possibly due to an increased risk of infection. Efforts should be made to improve adherence.

Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review

BACKGROUND

To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men.

METHODS

In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence.

RESULTS

The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 ± 10.4 years. The median medication possession ratio (MPR, %) at years 1 and 2 was 90.1% (interquartile range (IQR) 19-100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR≧80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance.

CONCLUSIONS

Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.

Mixed-treatment comparison of anabolic (teriparatide and PTH 1-84) therapies in women with severe osteoporosis

PURPOSE

The recent development of compounds with anabolic action on bone have increased the range of therapeutic options for the treatment of osteoporosis and the prevention of fractures. Two major PTH analogs, the synthetic full-length 1-84 PTH molecule and the recombinant 1-34 N-terminal fragment (teriparatide), are available for the treatment of osteoporosis in many countries. There have bee no comparative trials on the bone anabolic effects of these compounds.

MATERIALS AND METHODS

In this study we applied a mixed treatment comparison (MTC) to compare the efficacy of teriparatide versus PTH 1-84 for the prevention of vertebral and non-vertebral fractures in women with severe osteoporosis. With this approach the relative treatment effect of one intervention over another can be obtained in the absence of head-to-head comparison. Among the candidate papers selected for analysis, two randomized controlled trials investigating the effects of teriparatide and PTH 1-84 met the selection criteria and underwent MTC analysis.

RESULTS

Based on a fixed-effect MTC model analysis of data from two RCTs, teriparatide (20 µg/day) showed a 70% and 94% probability of being the best treatment for the prevention of vertebral and non-vertebral fractures, respectively. Together with a lack of statistical significance, this study has additional limitations. Some differences in trial procedures and populations exist; another limitation concerns the impossibility of carrying out a randomized-effect model MTC, due to sample exiguity. Furthermore, in order to consider unknown or unmeasured differences of covariates across trials, a random-effects approach would be preferred in order to assess the presence of heterogeneity across comparisons. In contrast, in our analysis a fixed-effect MTC model only was used.

CONCLUSIONS

Teriparatide is expected to provide a greater efficacy over PTH 1-84 with both vertebral and non-vertebral fracture prevention in postmenopausal women with severe osteoporosis.

Effects of denosumab on bone mineral density and bone turnover in postmenopausal women

Osteoporosis is a degenerative bone disease affecting approximately 10 million American adults. Several options are available to prevent development of the disease or slow and even stop its progression. Nonpharmacologic measures include adequate intake of calcium and vitamin D, exercise, fall prevention, and avoidance of tobacco and excessive alcohol intake. Current drug therapy includes bisphosphonates, calcitonin, estrogen or hormone therapy, selective estrogen receptor modulators, and teriparatide. Denosumab, a receptor activator of nuclear factor-K B ligand (RANKL) inhibitor, was recently approved by the United States Food and Drug Administration for treatment of postmenopausal osteoporosis. Patients treated with denosumab experienced significant gains in bone mineral density, rapid reductions in markers of bone turnover, and a reduced risk for new vertebral fracture. Compared with placebo, patients receiving denosumab 60 mg subcutaneously once every 6 months experienced gains in bone mineral density of 6.5-11% when treated for 24-48 months. One trial demonstrated the superiority of denosumab compared with alendronate, but the differences were small. The most common adverse reactions to denosumab include back pain, pain in extremities, musculoskeletal pain, and cystitis. Serious, but rare, adverse reactions include the development of serious infections, dermatologic changes, and hypocalcemia. The recommended dosing of denosumab is 60 mg every 6 months as a subcutaneous injection in the upper arm, upper thigh, or abdomen. Although beneficial effects on bone mineral density and fracture rate have been established in clinical trials, the risks associated with denosumab must be evaluated before therapy initiation. Of concern is the risk of infection, and denosumab should likely be avoided in patients taking immunosuppressive therapy or at high risk for infection. Therefore, bisphosphonates will likely remain as first-line therapy. Denosumab should be considered in patients unable to tolerate or who have adherence issues or contraindications to other therapies.

Impact of guideline implementation by a fracture nurse on subsequent fractures and mortality in patients presenting with non-vertebral fractures

INTRODUCTION

Systematic implementation of guidelines in patients presenting with a fracture increases identification of patients at high risk for subsequent fractures and contributes to a decreased fracture risk. Its effect on prevention of subsequent fractures and on mortality has not been documented. The aim of this study was to determine the impact of the implementation of specific guidelines on the risk of subsequent fractures and mortality in patients presenting with a non-vertebral fracture (NVF).

PATIENTS AND METHODS

Before-after impact analysis in consecutive patients older than 50 years who were admitted to the hospital with a NVF during 2 periods: pre-intervention group (n = 1,920, enrolled in 1999-2001) and intervention group (n = 1,335, enrolled in 2004-2006). The intervention consisted of a dedicated fracture nurse who systematically offered fracture risk evaluation and treatment according to available guidelines. The 2-year absolute risk (AR) and hazard ratio's (HR, with 95% confidence interval (CI)) of subsequent NVFs and mortality were analysed between both groups after adjustment for age, sex and baseline fracture location by multivariable Cox regression and by intention-to-treat.

RESULTS

The AR of subsequent fracture was 9.9% before and 6.7% after intervention, indicating a decrease of 35% in the risk of subsequent fracture (HR 0.65; CI: 0.51-0.84, after adjustment for age, sex and baseline fracture location) and 17.9% and 11.6%, respectively, for subsequent mortality, indicating a decrease of 33% in the risk of subsequent mortality (HR: 0.67; CI: 0.55-0.81, after adjustment for age, sex and baseline fracture location).

CONCLUSIONS

Systematic implementation of guidelines for fracture prevention by a dedicated fracture nurse immediately after a NVF is associated with a significant reduction of the 2-year risk of subsequent NVF and mortality.

The role and efficacy of denosumab in the treatment of osteoporosis: an update

INTRODUCTION

Bone strength determinants such as bone mineral density and bone quality parameters are determined by life-long remodeling of skeletal tissue. Denosumab is a fully human mAb receptor activator of NF-κB ligand, which selectively inhibits osteoclastogenesis, the end product of a cascade interaction among numerous systemic and local factors and osteoblasts. It has been approved for clinical use by the FDA in the US and by the European Medicines Agency in Europe since June 2010 (trade name Prolia(™), Amgen, Thousand Oaks, CA, USA).

AREAS COVERED

This review establishes the concerns and provides insights in issues concerning the cost-effectiveness and safety profile of this new pharmaceutical agent. There is an effort to clarify the special characteristics and the anti-catabolic role of denosumab in the bone tissue homeostasis and more specifically its potential clinical applications and clinical results in the field of postmenopausal osteoporosis.

EXPERT OPINION

Administrated as a subcutaneous injection every 6 months, denosumab has been shown to decrease bone turnover and increase bone mineral density in postmenopausal women with low bone mass or osteoporosis and reduce vertebral, hip and nonvertebral fracture risk in postmenopausal women with osteoporosis. The rapid, sustained and reversible effect in suppressing osteoclastic bone resorption, the return of responsiveness on rechallenge, its good tolerability and ease of administration are features that distinguish it from other antiresorptive therapies.

Risk of subsequent fracture and mortality within 5 years after a non-vertebral fracture

SUMMARY

The absolute 5-year risk of subsequent non-vertebral fractures (NVFs) in 1,921 patients presenting with a NVF was 17.6% and of mortality was 32.3%. These risks were highest within the first year, indicating the need to study which reversible factors can be targeted to immediately minimise subsequent fracture risk and mortality.

INTRODUCTION

NVFs are the most frequent clinical fractures in patients presenting at the emergency unit because of a clinical fracture. The aim of the study was to determine the 5-year absolute risk (AR) of subsequent NVF and mortality in patients at the time they present with a NVF.

METHODS

Between 1999 and 2001, 1,921 consecutive patients 50+ years from a level 1 trauma centre were included. All NVFs were confirmed on radiograph reports, and mortality was checked in the national obituary database. Available potential risk factors for a subsequent NVF and mortality (age, sex and baseline fracture location: major-hip, pelvis, multiple ribs, proximal tibia/humerus and distal femur; minor-all others) were expressed as hazard ratios (HR) with 95% confidence intervals (CI) using multivariable Cox regression analysis.

RESULTS

The AR for a subsequent NVF was 17.6% and was related to age (HR per decade, 1.44; 95%CI, 1.29-1.60). The AR for mortality was 32.3% and was related to age (HR per decade, 2.59; 95%CI, 2.37-2.84), male sex (HR, 1.74; 95%CI, 1.44-2.10), major fracture at baseline (HR, 5.56; 95%CI, 3.48-8.88; not constant over time) and subsequent fracture (HR, 1.65; 95%CI, 1.33-2.05). The highest risks were found within the first year (NVFs, 6.4%; mortality, 12.2%) and were related to age and, in addition, to baseline fracture location for mortality.

CONCLUSIONS

Within 5 years after an initial NVF, nearly one in five patients sustained a subsequent NVF and one in three died. One third of subsequent NVFs and mortality occurred within 1 year, indicating the need to study which reversible factors can be targeted to immediately prevent subsequent fractures and mortality.

Clinical fractures cluster in time after initial fracture

A history of fractures is a well recognised risk factor for a new clinical fracture. However, this subsequent fracture risk is not constant, but fluctuates over time, with the greatest increase in the years immediately after the initial fracture, followed by a gradual waning of risk toward the population risk. The clustering of fractures occurred regardless of age, gender and initial fracture location. It is therefore likely that fracture risk models, which take into account this fluctuation of fracture risk over time, will be more relevant in predicting an individual's subsequent fracture risk. Regardless of the cause of this clustering, these studies all strongly support the need for early action after an initial fracture to reduce the preventable risk of subsequent fractures with medical interventions that have been shown to immediately decrease the risk of fractures.

Compliance and treatment satisfaction of post menopausal women treated for osteoporosis. Compliance with osteoporosis treatment

Background

Adherence to anti-osteoporosis treatments is poor, exposing treated women to increased fracture risk. Determinants of poor adherence are poorly understood. The study aims to determine physician- and patient- rated treatment compliance with osteoporosis treatments and to evaluate factors influencing compliance.

Methods

This was an observational, cross-sectional pharmacoepidemiological study with a randomly-selected sample of 420 GPs, 154 rheumatologists and 110 gynaecologists practicing in France. Investigators included post-menopausal women with a diagnosis of osteoporosis and a treatment initiated in the previous six months. Investigators completed a questionnaire on clinical features, treatments and medical history, and on patient compliance. Patients completed a questionnaire on sociodemographic features, lifestyle, attitudes and knowledge about osteoporosis, treatment compliance, treatment satisfaction and quality of life. Treatment compliance was evaluated with the Morisky Medication-taking Adherence Scale. Variables collected in the questionnaires were evaluated for association with compliance using multivariate logistic regression analysis.

Results

785 women were evaluated. Physicians considered 95.4% of the sample to be compliant, but only 65.5% of women considered themselves compliant. The correlation between patient and physician perceptions of compliance was low (κ: 0.11 [95% CI: 0.06 to 0.16]). Patient-rated compliance was highest for monthly bisphosphonates (79.7%) and lowest for hormone substitution therapy (50.0%). Six variables were associated with compliance: treatment administration frequency, perceptions of long-term treatment acceptability, perceptions of health consequences of osteoporosis, perceptions of knowledge about osteoporosis, exercise and mental quality of life.

Conclusion

Compliance to anti-osteoporosis treatments is poor. Reduction of dosing regimen frequency and patient education may be useful ways of improving compliance.

Strategies for treatment to prevent fragility fractures in postmenopausal women

The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy.

Efficacy of ibandronate: a long term confirmation

Data deriving from randomized clinical trials, observational studies and meta-analyses, including treatment regimens unlicensed for use in clinical practice, clearly support that 150 mg once-monthly oral and 3 mg quarterly i.v. doses of ibandronate are associated with efficacy, safety and tolerability; notably both these marketed regimens, which largely correspond to ACE ≥10.8 mg, may in addition provide a significant efficacy on non-vertebral and clinical fracture (Fx) efficacy. The MOBILE and the DIVA LTE studies confirmed a sustained efficacy of monthly oral and quarterly i.v. regimens respectively, over 5 years. Furthermore, improved adherence rates with monthly ibandronate, deriving from studies evaluating large prescription databases, promise to enhance fracture protection and decrease the social and economic burden of postmenopausal osteoporosis.

Adherence to monthly and weekly oral bisphosphonates in women with osteoporosis

This primary care database survey evaluated whether osteoporotic women treated with bisphosphonates were more adherent to monthly than to weekly treatment. Both compliance (medication possession ratio [MPR]) and persistence (time to discontinuation) were superior in the monthly ibandronate treatment group. Better control of fracture risk may thus be achieved using monthly treatment regimens.

INTRODUCTION

Treatment adherence in osteoporosis is poor. The objective of this study was to evaluate whether monthly bisphosphonate treatment provided superior adherence than weekly treatment.

METHODS

We analysed medical claims from a national prescription database (Thales). All women aged >45 years receiving a first prescription of monthly ibandronate or weekly bisphosphonates in 2007 were included. Treatment adherence was monitored from initial prescription until January 2008. Compliance was measured by the MPR and persistence by the time from treatment initiation to discontinuation. Multivariate analysis was used to identify variables independently associated with adherence.

RESULTS

Twelve-month persistence rates were 47.5% for monthly ibandronate and 30.4% for weekly bisphosphonates. Compliance was significantly higher in the monthly cohort (MPR = 84.5%) than in the weekly cohort (MPR = 79.4%). After adjustment for potential confounding variables, women with monthly regimens were 37% less likely to be non-persistent (HR = 0.63 [0.56-0.72]) and presented a 5% higher mean MPR (84.5% versus 79.3%, p < 0.001) than women with weekly regimens. Other major factors associated with improved adherence were previous densitometry and calcium or vitamin D supplementation (p < 0.01).

CONCLUSIONS

Adherence to bisphosphonates may be superior for monthly treatment than for weekly treatment and may thus provide improved fracture protection.

Progress in osteoporosis and fracture prevention: focus on postmenopausal women

In the past decade, we have witnessed a revolution in osteoporosis diagnosis and therapeutics. This includes enhanced understanding of basic bone biology, recognizing the severe consequences of fractures in terms of morbidity and short-term re-fracture and mortality risk and case finding based on clinical risks, bone mineral density, new imaging approaches, and contributors to secondary osteoporosis. Medical interventions that reduce fracture risk include sufficient calcium and vitamin D together with a wide spectrum of drug therapies (with antiresorptive, anabolic, or mixed effects). Emerging therapeutic options that target molecules of bone metabolism indicate that the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.

Emerging treatments for postmenopausal osteoporosis - focus on denosumab

The pathway of the receptor activator of the nuclear factor κB ligand (RANKL), RANK and osteoprotegerin (OPG) plays a central role in coupling bone formation and resorption during normal bone turnover and in a wide spectrum of diseases characterized by disturbed bone remodeling, increased bone resorption and bone destruction (osteoporosis, Paget’s disease of bone, rheumatoid arthritis [RA], metastatic bone disease). Clinical trials indicate that denosumab, a RANKL-specific recombinant humanized monoclonal antibody, is effective in suppressing bone resorption, resulting in increase in bone mineral density (BMD) in post-menopausal women with low BMD, and has the potential to prevent progression of erosions in RA and of skeletal-related events in metastatic bone disease. The effects on fracture reduction in postmenopausal osteoporosis are awaited from the recently finished FREEDOM study. In clinical trials with denosumab, overall adverse events were similar to placebo or comparators, indicating a favorable safety profile in these diseases, which until now have been available up to 4 years, but data on long-term safety will be needed.

Bisphosphonates for postmenopausal osteoporosis: determining duration of treatment

Doctors who treat patients with osteoporosis are increasingly confronted with the question of how long to continue treatment with bisphosphonates (BPs), which have the unique characteristic of accumulating in the skeleton. Limited available long-term data suggest that such decisions should be made on a case-by-case approach and guided by an individual re-evaluation of clinical fracture risks and bone mineral density, efficacy, and safety issues. In patients who still have a high fracture risk after 5 years of treatment with BPs, continuing treatment could be considered, but stopping BPs could be appropriate in those with a low fracture risk after 5 years of treatment. Switching to recombinant human parathyroid hormone 1-34 or 1-84 is indicated when recurrent incident vertebral fractures occur despite adequate antiresorptive therapy for more than 1 year. However, the usefulness of more than 5 years of treatment with BPs needs to be proved with higher levels of evidence-based medicine.