“We want to use the drugs when we need them the most, and that’s changed our practice patterns a little bit,” Dr. Saag said. “We’re often saving these drugs [for patients in their] 60s, 70s and 80s instead of their 50s and 60s. We’re thinking about things like raloxifene, or even estrogen, earlier on. And we may have some new treatments on the horizon.”
Data on the impact of drug holidays on fracture risk conflict in observational studies, and it will likely be difficult to do randomized, controlled trials at this point because so few of today’s patients are on bisphosphonates for a long period of time, Dr. Saag said.
One group of experts recommended in a 2016 paper that—for postmenopausal women treated with oral bisphosphonates for at least five years or the IV form for three years—a drug holiday shouldn’t be considered unless they’ve had no hip, spine or other osteoporosis fractures before or during treatment; they have no bone mineral density T score of -2.5 or higher; and they are not a high fracture risk.3
But if a drug holiday is started, when should it be stopped?
“We don’t know when to restart,” Dr. Saag said. “We follow turnover markers. We look at bone density. We look at other risk factors, and we make a determination based on our best clinical judgment.”
Rather than a drug holiday, Dr. Saag said that, for some patients, he prefers the idea of a drug sabbatical, a period off the drug while other options are considered, rather than an indefinite time off bisphosphonates.
“Maybe we’ll get more evidence and, while we [explore options], I like the idea better of a sabbatical. Let’s not take a holiday, but let’s take a sabbatical and think about other things we might do in the meantime. … We could look at loss of BMD [bone mineral density] while on therapy. We could look at persistent turnover. Those would be things that might also influence our thinking.”
Other drugs could be considered as well, such as anabolics, denosumab, and raloxifene, all of which come with their own benefits and risks.
Dr. Saag emphasized that although a drug holiday may be a good idea for some patients on bisphosphonates, other drugs should not be considered for a holiday. “When you stop many of our drugs—when you stop estrogen, when you stop raloxifene, and when you stop denosumab—you lose bone rapidly,” he said. “So the idea of taking a break from these drugs is different than taking a break from bisphosphonates.”
