A Rapid Scoping Review of Recommendations for Deprescribing Bisphosphonates to Inform Clinical Decision Support

Objectives Bisphosphonates are central to osteoporosis management, but prolonged use may not be needed in some individuals, and/or increase the risk of rare adverse events.[1] Deprescribing guidance could support safe discontinuation decisions, including for individuals initiated on bisphosphonates to prevent glucocorticoid-induced osteoporosis (GIOP). This rapid scoping review examined deprescribing, drug holiday, and treatment duration recommendations within osteoporosis guidelines to inform decision support for rheumatologists and other clinicians.

Methods We conducted a rapid scoping review searching PubMed, Embase, MEDLINE, and gray literature. Leveraging a prior systematic review of guidelines published 2012-2022,[2] we updated the search to June 10, 2025, and expanded the scope to include GIOP and other secondary osteoporosis. Eligible guidelines contained ≥1 deprescribing recommendation for adults receiving bisphosphonates. One reviewer screened all records, with independent verification of selected records by a second reviewer. We extracted deprescribing criteria, considerations for monitoring and re-prescribing, and evidence grading.

Results We identified 291 records, reviewed 104 in full, and included 41 guidance documents from 23 countries (7 new, 34 retained from the original review.[2] Two-thirds (66%, n=27) relied on expert consensus without structured evidence grading, while 34% (n=14) used formal evidence appraisal methods including the GRADE framework (17%, n=7). All recommendations focused on deprescribing in individuals with initial indications for therapy. Most (93%, n=38) framed deprescribing as a drug holiday and generally recommended consideration after ≥5 years of oral or ≥3 years of intravenous bisphosphonate exposure in individuals without high fracture risk (34%, n=14), without prior or incident fractures on treatment (34%, n = 14), and/or with bone mineral density (BMD) T-score > −2.5 (29%, n=12). Three (7%) recommended deprescribing in other settings, including after glucocorticoid withdrawal in the setting of low fracture risk (n=1). Few incorporated individualized factors including life expectancy (5%, n=2), overall health (3%, n=1), or patient preferences (18%, n = 7). The majority (73%, n = 30) outlined when deprescribing should be avoided. Suggested drug holiday durations ranged 1-5 years. About half (44%, n = 18) advised BMD or fracture monitoring after deprescribing, and 29% (n = 12) recommended restarting therapy if BMD declined or a new fracture occurred.

Conclusion Most guidelines framed bisphosphonate deprescribing as drug holidays in postmenopausal osteoporosis, implying that future re-prescribing will be necessary. Recommendations were largely consensus-based. Practical guidance regarding deprescribing in patients who started bisphosphonates to prevent GIOP was scarce. Our results can inform decision support to guide safe deprescribing.

References [1.] Eastell R. J Bone Miner Res 2019;34:7-10. [2.] Jepsen DB. Eur Geriatr Med 2023;14:747-60.