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Review article: Medical guidelines

Vol. 147 No. 3334 (2017)

Osteoporosis drug treatment: duration and management after discontinuation. A position statement from the Swiss Association against Osteoporosis (SVGO/ASCO)

Cite this as:
Swiss Med Wkly. 2017;147:w14484


Antiosteoporotic drugs are recommended in patients with fragility fractures and in patients considered to be at high fracture risk on the basis of clinical risk factors and/or low bone mineral density. As first-line treatment most patients are started with an antiresorptive treatment, i.e. drugs that inhibit osteoclast development and/or function (bisphosphonates, denosumab, oestrogens or selective oestrogen receptor modulators). In the balance between benefits and risks of antiresorptive treatment, uncertainties remain regarding the optimal treatment duration and the management of patients after drug discontinuation. Based on the available evidence, this position statement will focus on the long-term management of osteoporosis therapy, formulating decision criteria for clinical practice.


  1. Recommendations of the Swiss Association against Osteoporosis (SVGO/ASCO). Prevention, Diagnostic and Treatment of Osteoporosis. 2015. Available from:
  2. Baber RJ, Panay N, Fenton A ; IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric. 2016;19(2):109–50. doi:.
  3. Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353–68. doi:.
  4. Kraenzlin ME, Meier C. Parathyroid hormone analogues in the treatment of osteoporosis. Nat Rev Endocrinol. 2011;7(11):647–56. doi:.
  5. Meier C, Lamy O, Krieg MA, Mellinghoff HU, Felder M, Ferrari S, et al. The role of teriparatide in sequential and combination therapy of osteoporosis. Swiss Med Wkly. 2014;144:w13952.
  6. Russell RG. Bisphosphonates: from bench to bedside. Ann N Y Acad Sci. 2006;1068(1):367–401. doi:.
  7. Meier C, Kraenzlin M. Osteoporose: Therapie-Update, 2. Teil. Medikamente heute und morgen. Swiss Med Forum. 2013;13:835–40. Article in German.
  8. Baron R, Ferrari S, Russell RG. Denosumab and bisphosphonates: different mechanisms of action and effects. Bone. 2011;48(4):677–92. doi:.
  9. Miller PD, Bolognese MA, Lewiecki EM, McClung MR, Ding B, Austin M, et al.; Amg Bone Loss Study Group. Effect of denosumab on bone density and turnover in postmenopausal women with low bone mass after long-term continued, discontinued, and restarting of therapy: a randomized blinded phase 2 clinical trial. Bone. 2008;43(2):222–9. doi:.
  10. Bone HG, Bolognese MA, Yuen CK, Kendler DL, Miller PD, Yang YC, et al. Effects of denosumab treatment and discontinuation on bone mineral density and bone turnover markers in postmenopausal women with low bone mass. J Clin Endocrinol Metab. 2011;96(4):972–80. doi:.
  11. Bagger YZ, Tankó LB, Alexandersen P, Hansen HB, Møllgaard A, Ravn P, et al. Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: the PERF study. Bone. 2004;34(4):728–35. doi:.
  12. Watts NB, Cauley JA, Jackson RD, LaCroix AZ, Lewis CE, Manson JAE, et al. No Increase in Fractures after Stopping Hormone Therapy: Results from the Women’s Health Initiative. J Clin Endocrinol Metab. 2017;102(1):302–8. doi:.
  13. Papadakis G, Hans D, Gonzalez-Rodriguez E, Vollenweider P, Waeber G, Marques-Vidal PM, et al. The Benefit of Menopausal Hormone Therapy on Bone Density and Microarchitecture Persists After its Withdrawal. J Clin Endocrinol Metab. 2016;101(12):5004–11. doi:.
  14. Rizzoli R, Kraenzlin M, Krieg MA, Mellinghoff HU, Lamy O, Lippuner K. Indications to teriparatide treatment in patients with osteoporosis. Swiss Med Wkly. 2011;141:w13297.
  15. Kaufman JM, Orwoll E, Goemaere S, San Martin J, Hossain A, Dalsky GP, et al. Teriparatide effects on vertebral fractures and bone mineral density in men with osteoporosis: treatment and discontinuation of therapy. Osteoporos Int. 2005;16(5):510–6. doi:.
  16. Kurland ES, Heller SL, Diamond B, McMahon DJ, Cosman F, Bilezikian JP. The importance of bisphosphonate therapy in maintaining bone mass in men after therapy with teriparatide [human parathyroid hormone(1-34)] [human parathyroid hormone(1-34)]. Osteoporos Int. 2004;15(12):992–7. doi:.
  17. Murad MH, Drake MT, Mullan RJ, Mauck KF, Stuart LM, Lane MA, et al. Clinical review. Comparative effectiveness of drug treatments to prevent fragility fractures: a systematic review and network meta-analysis. J Clin Endocrinol Metab. 2012;97(6):1871–80. doi:.
  18. Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, et al.; FLEX Research Group. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006;296(24):2927–38. doi:.
  19. Black DM, Reid IR, Boonen S, Bucci-Rechtweg C, Cauley JA, Cosman F, et al. The effect of 3 versus 6 years of zoledronic acid treatment of osteoporosis: a randomized extension to the HORIZON-Pivotal Fracture Trial (PFT). J Bone Miner Res. 2012;27(2):243–54. doi:.
  20. Adler RA, El-Hajj Fuleihan G, Bauer DC, Camacho PM, Clarke BL, Clines GA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016;31(1):16–35. doi:.
  21. Ferrari S, Adachi JD, Lippuner K, Zapalowski C, Miller PD, Reginster JY, et al. Further reductions in nonvertebral fracture rate with long-term denosumab treatment in the FREEDOM open-label extension and influence of hip bone mineral density after 3 years. Osteoporos Int. 2015;26(12):2763–71. doi:.
  22. Bone HG. Ten years of denosumab treatment in postmenopausal women with osteoporosis: Results from the FREEDOM extension trial. In: Proceedings of the Annual Meeting of Bone and Mineral Research ASBMR 2015. 2015: Seattle, Oct 9–12.
  23. Chen JS, Sambrook PN. Antiresorptive therapies for osteoporosis: a clinical overview. Nat Rev Endocrinol. 2011;8(2):81–91. doi:.
  24. Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O’Ryan F, et al.; International Task Force on Osteonecrosis of the Jaw. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res. 2015;30(1):3–23. doi:.
  25. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014;29(1):1–23. doi:.
  26. Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res. 2012;27(12):2544–50. doi:.
  27. Edwards BJ, Bunta AD, Lane J, Odvina C, Rao DS, Raisch DW, et al. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am. 2013;95(4):297–307. doi:.
  28. Schwartz AV, Bauer DC, Cummings SR, Cauley JA, Ensrud KE, Palermo L, et al.; FLEX Research Group. Efficacy of continued alendronate for fractures in women with and without prevalent vertebral fracture: the FLEX trial. J Bone Miner Res. 2010;25(5):976–82. doi:.
  29. Black DM, Bauer DC, Schwartz AV, Cummings SR, Rosen CJ. Continuing bisphosphonate treatment for osteoporosis--for whom and for how long? N Engl J Med. 2012;366(22):2051–3. doi:.
  30. Cosman F, Cauley JA, Eastell R, Boonen S, Palermo L, Reid IR, et al. Reassessment of fracture risk in women after 3 years of treatment with zoledronic acid: when is it reasonable to discontinue treatment? J Clin Endocrinol Metab. 2014;99(12):4546–54. doi:.
  31. Lamy O, Gonzalez-Rodriguez E, Stoll D, Hans D, Aubry-Rozier B. Severe rebound-associated vertebral fractures after denosumab discontinuation: nine clinical cases report. J Clin Endocrinol Metab. 2017;102(2):354–8. [doi:.].
  32. Anastasilakis AD, Polyzos SA, Makras P, Aubry-Rozier B, Kaouri S, Lamy O. Clinical Features of 24 Patients With Rebound-Associated Vertebral Fractures After Denosumab Discontinuation: Systematic Review and Additional Cases. J Bone Miner Res. 2017 Feb 27. [Epub ahead of print] doi:.
  33. Brown JP, et al. Discontinuation of denosumab and associated vertebral fracture incidence: Analysis from FREEDOM and its extension. In: Proceedings of the Annual Meeting of Bone and Mineral Research ASBMR 2016. 2016: Atlanta, Sept 16–19.
  34. McClung MR, Wagman RB, Miller PD, Wang A, Lewiecki EM. Observations following discontinuation of long-term denosumab therapy. Osteoporos Int. 2017;28(5):1723–32. doi:.
  35. Uebelhart B, Rizzoli R, Ferrari S. Prior exposure to bisphosphonate prevents the rebound of bone turnover markers after denosumab therapy. Osteoporos Int. 2017; (in production).
  36. Leder BZ, Tsai JN, Jiang LA, Lee H. Importance of prompt antiresorptive therapy in postmenopausal women discontinuing teriparatide or denosumab: The Denosumab and Teriparatide Follow-up study (DATA-Follow-up). Bone. 2017;98:54–8. doi:.
  37. Beaudoin C, Jean S, Bessette L, Ste-Marie LG, Moore L, Brown JP. Denosumab compared to other treatments to prevent or treat osteoporosis in individuals at risk of fracture: a systematic review and meta-analysis. Osteoporos Int. 2016;27(9):2835–44. doi:.
  38. Tsai JN, Uihlein AV, Lee H, Kumbhani R, Siwila-Sackman E, McKay EA, et al. Teriparatide and denosumab, alone or combined, in women with postmenopausal osteoporosis: the DATA study randomised trial. Lancet. 2013;382(9886):50–6. doi:.
  39. Leder BZ, Tsai JN, Uihlein AV, Wallace PM, Lee H, Neer RM, et al. Denosumab and teriparatide transitions in postmenopausal osteoporosis (the DATA-Switch study): extension of a randomised controlled trial. Lancet. 2015;386(9999):1147–55. doi:.

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