I received a question the other day about the use of bisphosphonates in patients who may have a limited life expectancy but have osteoporosis or are at risk for osteoporosis. It is a very good question and that determination is going to be made on a case by case basis.
Arguably the biggest challenge with this question is defining “limited life expectancy”. Are we talking about 2 weeks, 2 months, or two years? The shorter the life expectancy, the less likely we are to use bisphosphonates to improve bone mineral density and reduce the risk of osteoporotic fractures.
Why is that? Improving bone mineral density takes a significant amount of time. That exact timeframe to benefit isn’t well spelled out in most studies pertaining to these drugs. Many of the studies on bisphosphonates (and denosumab) involve monitoring patients at 12 months, 24 months, etc. What this means is that it may be hard to determine how much benefit a patient is going to have at months 3, 6, or even 9.
To help give you a sense of some clinical factors to think about, here are some questions I would consider.
- Are they on hospice or going to start hospice soon? If so, this is definitely a patient with a limited life expectancy. I can’t imagine a scenario where I would recommend starting a bisphosphonate for osteoporosis management in this type of situation.
- What does the patient and/or family think? This may be one of the easiest and most important determining factors to help you assess whether or not to start treatment.
- What conditions do they have and how severe are they? Dementia, Parkinson’s and CHF are examples of disease states that are progressive in nature. If the patient is already at a moderate to severe stage in their disease process, this is a good time to review the life expectancy and help make a determination on osteoporosis management.
- Have they been treated in the past? I have seen cases where when it wasn’t investigated thoroughly, and we found out that the patient had their bisphosphonate stopped by another provider. Determining how long they had been on it is also important.
- Review of personal fractures, T-score and other clinical factors is important in any osteoporosis assessment.
- Assess family history of fractures and risk for severe osteoporosis.
- Are they taking medications that may increase their osteoporosis risk? A drug like phenytoin is a good example of a medication that can do this.
Did I miss anything on bisphosphonates in patients with limited life expectancy and what other considerations might you think about?
Looking for more on osteoporosis? Check out these medication misadventures!
- 30 medication mistakes PDF
- 18+ Page Drug Interaction PDF
- 10 Commandments of Polypharmacy Webinar based on my experiences in clinical practice
Patient has diagnosis of multiple myeloma and receiving treatment since 2014. Had Zoledronic acid at start of each treatment cycle x 2 years when Zoledronic acid was discontinued. Chemotherapy treatments which include dexamethasone continue. Two weeks ago, patient fractured humerus, from a handshake. Patient is 81 years old and despite pain, drowsiness and fatigue, is in otherwise good spirit. No other medical conditions. Renal function is good. Would you recommend starting a bisphosphonate, like pamidronate every 3-4 weeks or resuming Zoledronic acid? What patient parameters would preclude resuming a bisphosphonate in this case? Anything that should be ruled out before resumption?
I would also consider issues like do they have severe reflux? Would sitting upright after administration be a significant burden on the patient/caregiver?
Great questions to consider, thanks for sharing!
Excellent post as usual!
I would also factor in mobility and falls risk.