A 70-year-old woman with a T-score of -3.2 at the femoral neck sustains a fragility fracture of the distal radius. She is started on alendronate 70 mg weekly. After 5 years of treatment, she is reassessed. When should a drug holiday (temporary discontinuation) be considered for oral bisphosphonates?

• A After 1 year of treatment in all patients
• B After 3-5 years in low-to-moderate risk patients or 5-10 years in high-risk patients ✓
• C Drug holidays are not recommended; bisphosphonates should be continued indefinitely
• D Only after 10 years regardless of fracture risk

Explanation

Bisphosphonate drug holidays are recommended due to concern for atypical femoral fractures and osteonecrosis of the jaw with prolonged use. Current guidelines (NOF/AACE/Endocrine Society): after 3-5 years of oral bisphosphonate (or 3 years of IV zoledronic acid) — patients at LOW-TO-MODERATE risk can take a 2-3 year holiday (as bisphosphonate residual skeletal effect persists for years); patients at HIGH risk (prior hip/vertebral fracture, very low T-score) should continue for 5-10 years. Reassess after holiday with bone density and fracture risk tools.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.