Therapeutic holidays in osteoporosis: Long-term strategy of treatment with bisphosphonates

Abstract Oral bisphosphonates (BFs) are drugs widely used in the treatment of osteoporosis and placed as first-line treatment for osteoporosis in most clinical guidelines. BFs are effective drugs that reduce the incidence of fractures and even reduce mortality. Because of their great affinity for bone, BFs have shown that even when they are discontinued still offer a latent protective effect on bone mineral density, maintaining their anti-fracture effect. However, prolonged use for years has been linked to the gradual emergence of complications such as osteonecrosis of the jaw or atypical femur fractures, which have raised questions as when to hold and when to make a final or temporary break, recognized as periods of rest or “therapeutic holidays” of these drugs. Thus, in patients treated with BF for a period of 3–5 years with a low risk of fracture, the drug should be discontinued and restarted when there is an indication for treatment. In contrast, in patients with moderate risk, therapeutic holidays are advised, while reassessing after 2–3 years for restarting purposes. Finally, in patients with high risk of fracture, treatment with BF should not be withdrawn.