44 BPJ Issue 46
CORRESPONDENCE
Guidance for stopping alendronate
Dear Editor,
A patient recently asked me “How long should I stay on
alendronate?” A very good question that had me struggling. A
local rheumatologist has stopped alendronate in several of my
patients after ve years. “A practical guide to stopping medicines
in older people” (BPJ 27, Apr 2010) mentioned alendronate as a
medication that could be considered for possible cessation in the
elderly, but gave no clear guide on who and when. My limited
reading suggests that a holiday from alendronate should be
considered after ve years in most and ten years in the rest, as
alendronate has an ongoing eect after its cessation, the maximal
bone strength is attained at three years and additional risk of
atypical fracture occur after that duration. I am unsure what to
do here? This is an expensive medication and its unnecessary
use would be good to eliminate. Wonder if you can answer my
questions? What is the optimal duration of alendronate treatment,
in whom should we stop it and what monitoring is required?
Brian Scrimshaw
General Practitioner, Wanganui
Treatment with a bisphosphonate, such as alendronate, has
proven benets in terms of the prevention of bone loss and the
reduction of fractures in males or post-menopausal females
with osteoporosis. However, alendronate is associated with
adverse eects such as oesophagitis, oesophageal ulcers and
strictures, as well as a very small increased risk of osteonecrosis
of the jaw and atypical femur fractures.
1
Therefore the benets
vs. risks of alendronate treatment must be carefully weighed
up and regular review should take place.
There is currently a lack of evidence to form a consensus on
the optimal length of alendronate treatment and when, if
ever, it should be stopped, and for how long. Many clinicians
recommend that alendronate should be interrupted
periodically. In theory, this is to allow recovery of bone
turnover, which is suppressed during treatment, but it is
unknown whether this suppression contributes to the rare
adverse eects associated with alendronate.
1
The benecial
effect of alendronate remains for three to five years after
ceasing treatment.
In a patient who has taken alendronate for ve years and
whose bone density is no longer in the osteoporotic range,
discontinuing alendronate is a reasonable approach. The
patient is likely to have substantial residual anti-resorptive
activity during this period. N.B. this can be checked through the
measurement of serum P1NP, with a value < 35 µg/L indicative
of signicant inhibition of bone resorption, however, this test
is not usually carried out in general practice. Bone density and
fracture risk can be re-evaluated (using DEXA scan) after two
years o treatment, and alendronate resumed in patients with
a 10-year hip fracture risk greater than 3% (calculated using
FRAX).
If patients are still at high risk after ve years of alendronate
treatment (bone mineral density remains low, fragility fracture
has occurred), the risk of stopping treatment is likely to exceed
the risk of continuing.
1
In a recent perspective article in the New England Journal of
Medicine, the authors concluded the following, based on the
limited evidence about long-term alendronate use:
2
Patients with bone density T-scores of −2.5 or below at
the femoral neck, after three to ve years of treatment,
benet the most from continuation
Patients with bone density T-scores between −2.5 to −2.0
and an existing vertebral fracture, after three to ve years
of treatment, may also benet from continuation
Patients with bone density T-scores above −2.0 at the
femoral neck, after three to ve years of treatment, are
unlikely to benet from continuation
The authors also note that reduced doses may be considered if
alendronate is continued beyond ve years.
2
45
CORRESPONDENCE
ACKNOWLEDGEMENT Thank you to Professor Ian
Reid, Professor of Medicine and Endocrinology, Faculty
of Medical and Health Sciences, University of Auckland
for expert guidance in preparing this answer.
References
1. Khosla S, Bilezikian J, Dempster D, et al. Benefits and risks of
bisphosphonate therapy for osteoporosis. J Clin Endocrinol Metab
2012;97:2272-82.
2. Black D, Bauer D, Schwartz A, et al. Continuing bisphosphonate
treatment for osteoporosis – for whom and for how long? N Engl J
Med 2012;366(22):2051-3.
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or email: [email protected].nz
Pneumovax 23 repeat doses: correction
In the article “The management of community-acquired
pneumonia” BPJ 45 (Aug, 2012), it was stated that: adults aged
over 65 years and those at increased risk of complications
from pneumonia should receive the vaccine Pneumovax 23...
Doses should be repeated every three to ve years for people
at increased risk. Healthy people aged over 65 years generally
only require a single dose.
People at high risk should receive a second dose three to ve
years after their rst dose, not every three to ve years.
Antibiotic treatment for syphillis: correction
In the article “Syphilis: testing for the great imitator” Best Tests
(June 2012), it was stated that Penicillin G (benzylpenicillin
sodium) was the rst-line treatment for all stages of syphilis.
Benzathine benzylpenicillin is in fact the preferred treatment
at all stages, as it is longer-acting. Treatment is usually initiated
by a sexual health or infectious diseases physician.
