Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Bisphosphonate Use & Fractures in Older Women

J Am Geriatr Soc; 2017 Sep; Drieling, et al

Among older women at high risk for fracture, bisphosphonate use for 10 to 13 years was associated with higher risk of any clinical fracture compared with 2 years of use, a recent study found. 5,120 older women (median age 80 years) from the Women’s Health Initiative who reported at least 2 years of bisphosphonate use in 2008-2009 were included and following for 3.7 ±1.2 years. Researchers estimated the association between duration of bisphosphonate use (3-5, 6-9, 10-13 years) and fracture using 2 years as the referent group. They found:

  • There were 127 hip, 159 wrist or forearm, 235 clinical vertebral, and 1,313 clinical fractures.
  • In multivariate-adjusted analysis, 10 to 13 years of bisphosphonate use was associated with higher risk of any clinical fracture vs 2 years of use (HR, 1.29).
  • This association persisted in analyses limited to women with a prior fracture (HR, 1.30) and women with no history of cancer (HR, 1.36).
  • The association of 10 to 13 years of use compared with 2 years of use was not statistically significant for hip, clinical vertebral, or wrist fracture.

Drieling RL, LaCroix AZ, Beresford SAA. Long-term oral bisphosphonate therapy and fractures in older women: The Women’s Health Initiative. J Am Geriatr Soc. 2017:65(9):1924-1931. doi:10.1111/jgs.14911.


The information in this well performed, real-world study supports recommendations of the recent American College of Physicians guidelines on the management of osteoporosis that state women with osteoporosis (T-score <2.5) should be offered pharmacologic treatment to reduce the risk for hip and vertebral fractures. The recommended medications are the bisphosphonates—alendronate, risedronate, zoledronic acid—or the RANKL inhibitor monoclonal antibody denosumab. The guideline recommends 5 years of treatment.1 The current study lends further support and confidence to the recommended duration of treatment. As discussed in an editorial in this month’s Journal of the American Geriatric Society, while bisphosphonates prevent fractures and reduce mortality in individuals with osteoporosis, prescriptions of bisphosphates for eligible individuals with osteoporosis decreased 50% from 2008-2012.2 Prescriptions have decreased due to the emerging evidence about bisphosphonates leading to osteonecrosis of the jaw (ONJ) and atypical femur fractures (AFFs) which are rare but concerning events. The incidence of these adverse effects increases with increased duration of use. The prevention of osteoporotic fractures stands to benefit many women, and by limiting the duration of use to 5 years or less we can maximize the benefit risk ratio. —Neil Skolnik, MD

  1. Qaseem A, Forciea MA, McLean RM, et al. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(11):818-839. doi:10.7326/M15-1361.
  2. Lyles J. Have we learned how to use bisphosphonates yet? J Am Geriatr Soc. 2017;65(9):1902–1903. doi:10.1111/jgs.14948.

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