Current Challenges in Osteoporosis Treatment Discontinuation

Osteoporosis is a chronic disease that may require lifelong therapy. Therefore, evidence-based approach regarding the efficacy and safety of long‐term osteoporosis therapy and therapy discontinuation is important. The most important goals for osteoporosis and fragility fracture patients are the recovery of pre-fracture functional level and reduction of fracture risk. There has been increasing consensus that a treat-to-target (T2T) strategy is applicable to osteoporosis and that bone mineral density (BMD) is currently the most clinically appropriate target. However, there is no clear consensus with regard to the definition of a specific BMD treatment target and timeframes applicable to T2T in osteoporosis, and these would need to be individually determined. Treatment with bisphosphonates may be interrupted after 3-5 years, only in patients in whom fracture risk is low or lowered because of the treatment itself. It is recommended never to discontinue treatment in patients with one or more prevalent osteoporotic fractures or in whom the BMD values are still below -2.5 (T score). Recent reports imply that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures. Patients considered at high fracture risk should either continue denosumab therapy for up to ten years or be switched to an alternative treatment. For patients at low-risk, a decision to discontinue denosumab could be made after five years, but bisphosphonate therapy should be considered to reduce or prevent the rebound increase in bone turnover.