Table 3.

Key Considerations for Bisphosphonate Drug Holidays

Drug holidays should not be a universal practice in all long‐term BP users. High‐risk patients who embark on an injudicious BP drug holiday are at risk of fragility fractures.

In the appropriate setting, BP drug holidays are safe, reduce the risk of AFF while benefiting from continued anti‐fracture effects of long‐term BPs. Drug holidays neutralize the risk of AFF after long‐term treatment. Beyond two years, the increased risk of fragility fracture with a prolonged drug holiday should be considered.

Different BPs should influence drug holiday decisions differently. Whilst zoledronic acid confers durable, continued anti‐fracture effects, patients embarking on a drug holiday from risedronate may experience relatively more rapid declines in bone density and rebounds in fracture risk. Longer‐term treatment is therefore required with risedronate and clinicians may consider the possibility of a dose of zoledronic acid in risedronate users to promote durability prior to a holiday.

Hip BMD is a robust predictor of fracture in patients embarking on a BP drug holiday. In particular, patients with a rapidly declining hip bone density or a hip T‐score ≤ −2.5 SD may be at risk of holiday‐related fractures.

Current evidence does not support the use of BTMs in decisions on BP drug holidays. While BTMs correlate with BMD trends during a drug holiday, validation of BTM thresholds or % change that would identify patients at risk of holiday‐related fractures has not been established.

BP drug holidays are not drug retirements. Osteoporosis is a chronic, progressive disease and a period of BP use is not curative. A person's risk of fragility fracture will increase with a longer BP drug holiday and clear parameters triggering re‐initiation of treatment should be decided early on.