Bisphosphonates discontinuation

Raloxifene combined with alendronate produced greater BMD effects than raloxifene alone, but not greater than alendronate alone. The impact on fracture outcomes, however, is not yet known. Contrary to bisphosphonate discontinuation—in which the achieved BMD is maintained or decreased much more slowly than among those in the placebo group—raloxifene discontinuation results in BMD decreasing immediately at a rate similar to that of placebo. ... 

BMD will increase and the risk of fractures will decrease in women taking HRT. However, when therapy is discontinued, a decline in BMD will resume at the same rate as in women not on HRT. Therefore, therapy for osteoporosis prevention should be considered long term. Since HRT should be maintained only for the short term, alternative therapies such as bisphosphonates or raloxifene should be considered as first-line therapy for the prevention of postmenopausal osteoporosis, in addition to appropriate doses of calcium and vitamin D. Because of the risks associated with HRT, it should not be prescribed solely for the prevention of osteoporosis. 

Several studies have evaluated the long-term efficacy and safety of bisphosphonates in postmenopausal women. One study evaluated the use of alendronate over a 10-year period and found no difference in adverse effects between women who received alendronate for 10 years and women who discontinued alendronate after 5 years. Women who discontinued alendronate after 5 years continued to experience sustained increases in bone mineral density compared with baseline values and a reduction... 

Osteoporosis Encourage patients to ingest adequate amounts of calcium and vitamin D, encourage smokers to discontinue tobacco use, and consider initiation of medications for osteoporosis (e.g., bisphosphonates, calcitonin, and parathyroid hormone) if the patient is taking glucocorticoids for an extended period of time or if the patient has evidence of low bone mineral density.15,41... 

BMD increases are dose dependent and greatest in the first 6 to 12 months of therapy. Small increases continue over time at the lumbar spine but plateau after 2 to 5 years at the hip. After discontinuation, the increased BMD is sustained for a prolonged period that varies depending on the bisphosphonate used. 

Raloxifene decreases vertebral fractures and increases spine and hip BMD, but to a lesser extent than bisphosphonates. After discontinuation, the beneficial effect is lost and bone loss returns to age- or disease-related rates. 

Discontinuation of therapy results in a decrease in BMD, but some antifracture efficacy appears to be maintained. Sequential therapy with teriparatide followed by an antiresorptive agent (e.g., bisphosphonate) should be considered to maintain BMD gains. 

Gl irritation/disorders Bisphosphonates cause local irritation of the upper Gl mucosa. Alert physicians to any signs or symptoms signaling a possible esophageal reaction and instruct patients to discontinue bisphosphonates and seek medical attention if they develop dysphagia, odynophagia, retrosternal pain, or new or worsening heartburn. 

A dental examination with appropriate preventive dentistry should be considered prior to treatment with bisphosphonates in patients with concomitant risk factors (e.g., cancer, chemotherapy, corticosteroid use, poor oral hygiene). While on bis-phosphonate treatment, patients with concomitant risk factors should avoid invasive dental procedures if possible. For patients who develop osteonecrosis of the jaw while on bisphosphonate therapy, dental surgery may exacerbate the condition. For patients requiring dental procedures, there are no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of osteonecrosis of the jaw. 

Studies needed to assess place in therapy with other bisphosphonates Inhibition of bone loss in osteoporosis maypersist up to 2 yr afterb mo of treatment and discontinuation of drug... 

Anterior segment inflammation may be treated without cessation of the bisphosphonate, but deeper inflammation of the uvea and sclera may require discontinuation of the systemic therapy. 

In a retrospective analysis of spontaneous adverse event reports encompassing more than 430, 000 patients who had received zoledronic acid between August 2001 and March 2003, only 72 cases of renal failure were identified by the US Food and Drug Administrahon [78, 79]. It should be noted, however, that patients with risk factors for renal deterioration, including advanced cancer, previous bisphosphonate exposure, and use of nonsteroidal anti-inflammatory medications, may have contributed to the progression of renal failure [79]. Because of the potentially serious nature of this adverse event, it is recommended to monitor renal funchon in patients with cancer before each infusion of zoledronic acid, provide adequate hydration, and modify or discontinue treatment if renal complications occur [30, 78, 79]. 

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