Duration and sequence of therapy in postmenopausal females and males aged 50 years and older who receive anti-osteoporosis medications*
| Recommendations | Strength of recommendation and certainty of evidence† |
|---|---|
| 5. Duration and sequence of therapy | |
| 5.1. For people on bisphosphonates, we suggest initial therapy for a duration of 3–6 yr. Remark: Six years of therapy is appropriate for individuals with a history of hip, vertebral or multiple nonvertebral fractures, or new or ongoing risk factor(s) for accelerated bone loss or fracture.‡ When using zoledronic acid, dosing less frequently than annually may be appropriate. (46) | Conditional recommendation; low-certainty evidence |
| 5.2. When there is inadequate response or ongoing substantial concern for fracture during bisphosphonate therapy, good practice includes extending or switching therapy, reassessing for secondary causes and seeking advice from a consultant with expertise in osteoporosis, if needed. Remark: Inadequate response to treatment should be considered when > 1 fracture or substantial bone density decline (e.g., ≥ 5%) occurs despite adherence to an adequate course of treatment (typically > 1 yr). However, fractures or bone density decline during therapy do not always indicate inadequate response to treatment (e.g., secondary causes of osteoporosis, falls, BMD imprecision errors). | Good practice statement |
| 5.3. For people on denosumab, we suggest long-term uninterrupted therapy. Remarks: The injection schedule of every 6 mo should not be delayed by more than 1 mo because of the risk of rapid bone loss and vertebral fractures. Duration of therapy may be assessed after 6–10 yr and may be dependent on previous bisphosphonate therapy and individualized risk for atypical femoral fracture and osteonecrosis of the jaw. | Conditional recommendation; low-certainty evidence |
| 5.4. For people discontinuing denosumab after ≤ 4 doses, we suggest transitioning to a bisphosphonate 6 mo after the last dose of denosumab to reduce the risk of rapid bone loss. We suggest bisphosphonate therapy for 1 yr and then reassessing the need for ongoing transition therapy. Remark: Discontinuation of denosumab may be appropriate for people for whom treatment with denosumab is no longer warranted or for those who develop intolerance or contraindications to denosumab. | Conditional recommendation; low-certainty evidence |
| 5.5. For people discontinuing denosumab after ≥ 5 doses where the risk of rapid bone loss or vertebral fractures is high (e.g., those with prevalent vertebral fractures), good practice includes seeking advice from a consultant with expertise in osteoporosis on how to transition to an alternative therapy. | Good practice statement |
| 5.6. After a course of anabolic therapy, we suggest transitioning to an antiresorptive agent to maintain bone density gains. | Conditional recommendation; low-certainty evidence |
Note: BMD = bone mineral density.
↵* See Figure 2 for integrated approach.
↵† See Table 1 for definitions.
↵‡ See risk factors in Figure 1 and Appendix 1, Supplementary Table 5 (causes of secondary osteoporosis), available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221647/tab-related-content