If you have been offered bisphosphonates by your GP — or are considering them — this article will not tell you what to do. That decision is properly made between you and a clinician who knows your case. It will, however, set out where bisphosphonates sit in the wider picture, so that the conversation with your GP is a better-informed one.
- Bisphosphonates slow bone loss but do not build new bone — that distinction matters in deciding when and for whom they are appropriate.
- The LOC clinical pathway is reversal-first: the aim is to rebuild bone before reaching for therapies that slow its loss.
- There are specific clinical situations in which bisphosphonates are the right choice — a consultant-led assessment identifies which situation applies.
- Long-term use carries known risks, including osteonecrosis of the jaw and atypical femoral fractures, which are worth raising explicitly with your GP.
- If the proposed plan begins and ends with a prescription, without investigation of why bone loss has occurred, a specialist opinion is reasonable.
What bisphosphonates do
Bisphosphonates — alendronate, risedronate, ibandronate, zoledronate — are anti-resorptive drugs. They slow the rate at which bone is broken down by inhibiting the osteoclast cells that perform that breakdown. Over months and years, this stabilises bone density and reduces fracture risk in patients at meaningful risk.
They do not build new bone. They slow its loss. That distinction matters in deciding where, when, and for whom they are useful. A patient with severe osteoporosis and high short-term fracture risk may benefit from the stabilising effect immediately. A patient with early-stage bone loss and no acute fracture risk may have more to gain from a pathway that first addresses whether bone can be actively rebuilt before resorption is suppressed.
Understanding this mechanism is also the basis for understanding the long-term use cautions — because osteoclasts, whose activity bisphosphonates suppress, are also involved in normal bone remodelling. Suppressing that process indefinitely carries consequences.
The LOC clinical position
At the London Osteoporosis Clinic, the clinical pathway is reversal-first. The aim of treatment is to rebuild bone, where rebuilding is possible, before reaching for therapies whose mechanism is to slow loss. Where reversal is achieved on DXA, the next phase is consolidation — protecting the gains. Bisphosphonates sit at the end of that pathway, used selectively, often briefly, and not as a default first-line therapy.
This is intentionally distinct from the antiresorptive-first approach that has been the default in UK primary care. Bisphosphonates have a genuine and useful place in the management of osteoporosis; the question is where they sit, not whether they have a place at all.
The distinction also reflects a broader principle. Before any drug is prescribed for bone loss, the question should be asked: why is bone being lost? Reversible causes — vitamin D deficiency, hormonal depletion, secondary drivers such as prolonged steroid use, coeliac disease, or hyperthyroidism — should be identified and addressed first. Prescribing an anti-resorptive on top of an unaddressed cause is treating the measurement rather than the condition.
When bisphosphonates make particular sense
There are clinical situations in which an anti-resorptive agent is the right next step — for example, in patients in whom active rebuilding has already been achieved and the priority is protection of those gains; in patients for whom anabolic therapies are contraindicated; and in patients with high short-term fracture risk for whom the speed and reliability of the anti-resorptive effect outweighs other considerations. A consultant-led assessment is the right way to identify which situation applies.
In some patients, particularly those with very low T-scores or a recent fragility fracture, bisphosphonates may form part of a combination approach — used alongside nutritional and hormonal optimisation rather than as a standalone prescription. The context of the individual case is everything.
Long-term use: what patients should know
Bisphosphonates are typically prescribed for a defined duration — often three to five years for oral agents, with a review at that point. Prolonged or open-ended use, without structured review, is associated with two rare but serious complications that patients have a right to understand before starting treatment.
Osteonecrosis of the jaw (ONJ) is a condition in which bone tissue in the jaw fails to heal, most commonly following dental procedures such as extractions. The absolute risk in patients taking oral bisphosphonates at standard doses for osteoporosis is low — significantly lower than in patients receiving high-dose intravenous bisphosphonates for cancer. However, it is worth informing your dentist that you are taking or considering bisphosphonates, and ensuring any planned dental work is completed before starting treatment where possible.
Atypical femoral fractures (AFF) are stress fractures occurring in a specific location of the femur (thigh bone), associated with prolonged bisphosphonate use. The mechanism relates to suppression of normal bone remodelling: bisphosphonates prevent the routine replacement of micro-damaged bone, and over time, stress concentrations can develop. AFF is rare, and the fracture risk reduction bisphosphonates provide in the first years of treatment substantially outweighs this risk — but it is part of the reason that treatment duration is not open-ended, and why structured review matters.
If you have particular concerns about either complication, those concerns are reasonable and worth raising explicitly with your GP or consultant before starting treatment.
Questions worth taking to your GP appointment
If your GP has offered bisphosphonates, useful questions include:
- On what basis was the diagnosis made — DXA result, fracture history, family history, FRAX score? Is the full picture documented?
- Have reversible causes of bone loss been considered: vitamin D status, hormonal status, secondary causes such as steroid use, coeliac disease, hyperthyroidism, prolonged proton-pump-inhibitor use?
- What is the treatment duration being proposed, and what is the plan at the end of that duration?
- Has a consultant-led assessment been considered before starting?
These are not adversarial questions. They are the questions a well-structured clinical assessment would already have answered, and asking them helps ensure the proposed plan is built on a complete picture.
Where a specialist opinion is worth seeking
If the proposed treatment plan begins and ends with a bisphosphonate prescription, without an assessment of why bone loss has occurred and what else might be done about it, a second opinion from a clinic with a structured bone-health pathway is a reasonable next step. The aim is not to refuse the offered treatment — it is to place it in the right wider context.
A structured specialist assessment would typically include a full review of DXA results and FRAX risk, investigation of secondary causes of bone loss, hormonal and nutritional assessment, a proposed treatment sequence rather than a single drug, and a clear framework for monitoring and review.
We see many patients who have been prescribed bisphosphonates before a full assessment of why bone loss has occurred. The drug may be entirely appropriate — but the question should always come first: what is driving the bone loss, and has everything that could be addressed been identified? That answer shapes whether an anti-resorptive is the right first step, a later consolidation step, or part of a more structured sequence. Patients who arrive having already started bisphosphonates are not in the wrong place — we can still build a fuller picture and optimise the pathway from wherever they currently are. If you would like a consultant-led assessment, our team is available via our structured pathways.
Frequently Asked Questions
What is the difference between bisphosphonates and anabolic bone treatments?
Bisphosphonates are anti-resorptive — they slow the breakdown of bone by inhibiting osteoclast cells. Anabolic treatments, such as teriparatide or romosozumab, actively stimulate new bone formation. The LOC pathway prioritises anabolic therapy where rebuilding is possible, with bisphosphonates used subsequently to protect those gains — or as a first step where anabolic therapy is contraindicated or fracture risk is acute.
Can I stop taking bisphosphonates once my bone density improves?
This is a decision that should be made with your prescribing clinician, based on your DXA results, fracture risk, and the duration of treatment to date. For most patients on oral bisphosphonates, a structured review at three to five years is appropriate — at which point treatment may be continued, paused (a “drug holiday”), or replaced. Stopping without review is not recommended.
Are bisphosphonates safe to take long term?
Bisphosphonates are well-evidenced medications with a strong safety profile over the durations typically prescribed for osteoporosis. The risks associated with prolonged use — atypical femoral fractures and osteonecrosis of the jaw — are rare in patients taking standard oral doses, and the fracture-risk reduction in the early years of treatment substantially outweighs them. The key is structured review: treatment should not be open-ended without a clear plan for reassessment.
Medically reviewed by Dr. Taher Mahmud, Consultant Rheumatologist and Co-Founder, London Osteoporosis Clinic. Dr. Mahmud has over 25 years of clinical experience in bone health and osteoporosis management.
This article is for informational purposes only and does not constitute medical advice. Always consult a qualified clinician before starting, stopping, or changing any prescribed medication.
For further assessment or personalised guidance, please visit www.LondonOsteoporosisClinic.com.
