Bisphosphonate Drug Holiday and Fracture Risk: Reviewing the Evidence

Purpose of review This paper reviews evidence in support of or counter to the use of bisphosphonate (BP) drug holiday to minimize the occurrence of rare adverse events such as atypical femoral fracture, while maintaining the osteoporosis-related fracture prevention benefit conferred by the medication. Recent findings Fracture prevention benefit achieved with 3-5 years of BP treatment appears to be maintained during holiday for women at low to moderate risk of fracture. Women with bone mineral density T-score< - 2.5 or prior fragility fracture remain at high risk for fracture and continuation of therapy is advised. Additionally, evidence suggests that duration of BP use, level of adherence to therapy, and length of holiday may also influence fracture risk during holiday. There are few studies on AFF risk during drug holiday, but the limited evidence suggests a rapid decline in risk within the first 1-2 years of holiday. Summary BP drug holiday appears to be a reasonable part of osteoporosis treatment strategy for women at relatively low risk of osteoporosis-related fracture as assessed after initial treatment, white higher risk women may benefit from continued therapy rather than a BP holiday. Greater understanding of the influences of BP treatment duration and holiday length, and their interaction, can inform more individualized treatment decision-making.