Bisphosphonate Therapy in Aged Care: Assessing Continuation and Deprescribing for Osteoporosis Management

Osteoporosis is a common and serious condition among older adults in Australia, affecting over 1.2 million people with an additional 6.3 million having low bone density. For those living in residential aged care facilities (RACFs), the risk of fractures is significantly higher than the general population. Managing osteoporosis in aged care requires a careful balance between effective treatment and minimising unnecessary medication use. Bisphosphonates are the primary pharmacological agents used to treat osteoporosis, but as with any long-term therapy, there comes a time when deprescribing should be considered.

In this article, we will explore the benefits and risks of bisphosphonate therapy, the role of deprescribing in aged care, and practical tips for healthcare providers on how to manage osteoporosis medications for their residents.

The Issue of Inappropriate Medication

A significant challenge in residential aged care is the high prevalence of medication-related issues. According to the Medicine Safety: Take Care report, 98% of residents have at least one medication-related problem, and over half are exposed to potentially inappropriate medicines. Many older residents, especially those who are frail or nearing end-of-life, may be taking unnecessary or higher-risk medications that offer limited benefit while posing potential harm.

As older adults age and their health status changes, it is essential for healthcare providers to review their medication regimens regularly. This review should consider the likely benefits of continuing certain medications versus the potential for harm, with a focus on improving the resident’s quality of life.

Understanding Deprescribing

Deprescribing is the process of tapering, reducing, or discontinuing medications that are no longer necessary or may pose risks to the patient. The aim of deprescribing is to reduce polypharmacy and minimise adverse drug effects while maintaining or improving the patient’s overall well-being. Deprescribing is particularly relevant in aged care settings, where residents are often on multiple medications and are at increased risk of adverse drug reactions.

In the context of osteoporosis, deprescribing bisphosphonates may be appropriate for residents who have been on the medication long term, those at low risk of fractures, or those who have not experienced any new fractures during their treatment. However, deprescribing must be done cautiously and in consultation with the resident, their family, and other healthcare professionals.

Osteoporosis in Aged Care

Osteoporosis is a disease that weakens bones, making them brittle and more susceptible to fractures. For older adults, particularly those in RACFs, the risk of fractures is much higher than for those living in the community. Fractures, especially hip fractures, can lead to a significant decline in mobility, increased healthcare costs, and even higher mortality rates.

Vitamin D and calcium supplementation are essential for maintaining bone health, and residents in aged care facilities should aim for 1200–1500 mg of calcium per day through diet or supplements. Vitamin D supplementation is also recommended for all residents to reduce the risk of fractures. These nutritional interventions, along with pharmacological treatments like bisphosphonates, play a critical role in osteoporosis management.

Osteoporosis Treatment Options

In older adults, bisphosphonates are the first-choice pharmacological agents for preventing fractures. Common bisphosphonates used in the prevention and treatment of osteoporosis include:

Alendronate (Fosamax)
Risedronate (Actonel)
Zoledronic acid (Aclasta)

These medications reduce the risk of hip, vertebral, and non-vertebral fractures by about 50%, especially in post-menopausal women with osteoporosis.

The Use of Bisphosphonates in Aged Care

Bisphosphonates are effective at reducing the risk of fractures, particularly in older adults. For those who have experienced a fracture, bisphosphonate therapy can reduce the risk of subsequent fractures. However, bisphosphonates are poorly absorbed orally and must be administered carefully. For example, Alendronate should be taken with a full glass of water in the morning, and the resident should remain upright for at least 30 minutes to reduce the risk of esophageal irritation.

Risedronate may be taken with or without food, but residents must still remain upright for 30 minutes after administration. Gastrointestinal side effects are common, affecting up to 30% of those taking bisphosphonates.

Long-Term Use and Deprescribing Bisphosphonates

Most of the fracture prevention benefits of bisphosphonates are achieved within the first three to five years of therapy. For residents who have been on bisphosphonates for this duration, the need for continued therapy should be reassessed. Long-term use of bisphosphonates can increase the risk of rare but serious side effects, such as atypical femur fractures, osteonecrosis of the jaw, and severe allergic skin reactions.

For residents at low risk of fractures, a “drug holiday” or discontinuation of bisphosphonates may be appropriate. However, residents who remain at high risk of fractures should continue treatment after the initial five years.

FAQs

How do bisphosphonates work?

Bisphosphonates work by inhibiting the activity of osteoclasts, the cells responsible for breaking down bone. By reducing bone resorption, bisphosphonates help maintain bone density and reduce the likelihood of fractures.

How long should bisphosphonates be used?

Bisphosphonates are typically prescribed for three to five years, after which the need for continued treatment should be reassessed. For residents at low risk of fractures, a drug holiday may be considered, but those at high risk may need to continue therapy.

What is a drug holiday?

A drug holiday is a temporary discontinuation of bisphosphonates after long-term use. It is considered for residents at low-to-moderate fracture risk who have completed three to five years of treatment. The benefits of bisphosphonate therapy can persist for several years after discontinuation, particularly with alendronate and zoledronic acid.

Key Takeaways

Bisphosphonates are a commonly prescribed treatment for osteoporosis in older adults, particularly in residential aged care settings. They effectively reduce the risk of fractures, especially in the spine, hip, and other non-vertebral areas.
Long-term use of bisphosphonates should be regularly reassessed, as the benefits of continued treatment may diminish after 3 to 5 years.
Deprescribing bisphosphonates, especially in individuals at low fracture risk or those with no recent fractures, can be a safe and effective option to reduce potential side effects.
Common side effects of bisphosphonates include gastrointestinal irritation, atypical femur fractures, osteonecrosis of the jaw, and uveitis. The risk of these side effects increases with prolonged use.
Decisions around deprescribing bisphosphonates should be made in partnership with the resident, family, and healthcare professionals, considering both fracture risk and the resident’s overall health status.

Summary

Bisphosphonates are an important treatment for reducing fracture risk in residents with osteoporosis, particularly in aged care settings. However, prolonged use may lead to side effects such as gastrointestinal issues and, in rare cases, serious complications like osteonecrosis of the jaw or atypical fractures. For many residents, after several years of treatment, the benefits of bisphosphonates may plateau, making it essential to reassess the need for ongoing therapy. In some cases, deprescribing bisphosphonates can be a safe and effective way to minimise pill burden and adverse effects while maintaining bone health.

For more information on safe medication management, consult with Webstercare today.