Long-term therapy of osteoporosis with bisphosphonates: Evidence and implications for daily practice

Long-Term Use of Bisphosphonates in Osteoporosis

The rate of bone turnover increases around the time of menopause, and new bone may be remodeled before it is has been completely mineralized. If this is left untreated, osteoporosis often develops, leading to fractures, particularly of the spine and hip, which represent an enormous burden in terms of suffering, healthcare expenditure, disabilities and death. Bisphosphonates are potent inhibitors of bone resorption, which slow or arrest progressive bone loss. Continuous treatment with bisphosphonates reduces bone turnover, improves bone microarchitecture and increases bone mass, leading to greater mechanical strength and reduced fracture risk. Since osteoporosis is a chronic, progressive condition, treatment has to continue for many years. Therefore, the efficacy and safety of bisphosphonates, particularly alendronate and risedronate, have been evaluated in many thousands of patients for up to 10 years of continuous use. These drugs remain the cornerstone of osteoporosis treatment and appear to have favorable safety and efficacy profiles throughout long-term usage.

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.

Long-term experience with alendronate in the treatment of osteoporosis

Osteoporosis is characterised by increased bone turnover, low bone mass and impaired bone microarchitecture, leading to increased fracture risk. Effective anticatabolic therapies decrease fracture risk by reducing the rate of bone turnover, thereby maintaining bone microarchitecture and increasing bone mineral density. At present, potent oral bisphosphonates, such as alendronate (FOSAMAX; Merck & Co.), are preferred for the treatment of osteoporosis. Long-term clinical trial data demonstrate that alendronate is effective and generally well tolerated. Results from head-to-head studies and meta-analyses suggest that alendronate is more effective than certain other anticatabolic agents in the treatment of patients with osteoporosis.