After bisphosphonates then what

The bone builders are still effective. The blunting will vary but I have seen one study that had it at 10% vs 16% for Evenity, but others have different numbers. Have you talked with an endocrinologist?

It would likely depend on your current T-scores.

I don't think Prolia is suggested for this situation @serious. What does your endo say?

With more years on antiresorptives like Reclast or Prolia, after being on bisphosphonates for awhile prior (how long?) you might conceivably run into side effects (dental, atypical femur fracture) but ask your doctor. Everyone is different in their situation!

Bone builders will still be very helpful at least for most, according to studies I have seen.

I was on Fosamax for almost 5 years starting at age 54 and postmenopausal. My lumbar DEXA dropped from -2.5 to -2.7. My PCP said, "The Fosamax is not working. You should see an endocrinologist". That was in May of 2023. I stopped Fosamax and continued with only 1200 calcium and 1000 vitamin D. I saw an endocrinologist in October and she automatically prescribed Prolia. Fortunately I had learned quite a bit from reading up about Prolia in time to cancel the appointment. I decided to take a self-prescribed holiday from all treatment for a year until I can get my next DEXA with the TBS software (there's a machine in my hospital). This week I am seeing my endocrinologist and will get the bone turnover marker labs done. She was supportive and I think pleased that I had knowledge and was being decisive on my direction. I suspect I know more about it all than she does.

Serious, you've been on medication that preserve older bone and prevent both remodling and acquisition of new bone. And it has (likely) been effective at preventing fracture. Both reclast and prolia share that mode (by different mechanism) of prevention of bone loss. They are antiresorptive. And I think not adviseable.
Consider Forteo or Tymlos, no matter the bone markers. Redue the markers at 1 month and 2 months. Comparison to baseline is less important than the markers at 1 and 2.
The reductive effect of prior bisphonate use (and vitamin D use) are said to equalize to normal response within a year (observed, not proven).
Unless you have medical reasons prohibiting estrodial replacement, you might consider a patch or bioidentical not instead of but in addition to an anabolic.
I'm finishing a year of Forteo without negative effect and consider it the best on the market.
I will avoid Evenity because of known adverse effect and because of the unknown effect of blockage of the SOST pathway both in the brain and in the cardiovascular system.
Cheers to your endocrinologist. We are all looking for someone with those qualities.
Best luck in your choice of medication.

@gently thanks for this- always learning!

"The reductive effect of prior bisphosphonate use (and vitamin D use) are said to equalize to normal response within a year (observed, not proven)."

I am also concerned about the blockage of the SOST pathway and functions of sclerostin throughout the body, including CNS. After Tymlos I have done 4 months and am stopping. That was sort of a compromise plan: to get the burst of bone growth at the beginning of Evenity with minimal time suppressing sclerostin. I hope they are doing more research on suppression of sclerostin in the body.

that alternative timing is very interesting. I am reading that there are other such options on these other medications but so far no official declarations that this can be done.

My doctor, who specializes in osteo as well as RA and lupus, just put me on a "drug-free holiday" for a year (after 4-5 years of being on a bisphosphonate). Now, I am back on the bisphosphonate, likely for another 4-5 years. Mayo Clinic comments on why this is okay:
https://www.mayoclinic.org/diseases-conditions/osteoporosis/in-depth/osteoporosis-treatment/art-20046869#:~:text=So%20your%20doctor%20might%20suggest,medicine%20remains%20in%20your%20bone.
I assume my doctor doesn't want to ratchet up the treatment as my progress is "good enough" with the weekly pill.

I am surprised you are back on the bisphosphonate although I am getting some hints that this 5 year bisphosphonate limit is not really for a life time as I was lead to believe. What ever happened to the assertion that too much bisphosphonates will no longer work or make your bones brittle and subject to spontaneous fractures?

@serious this is an important question! I watched a video by Dr. Christopher Shuhart that another member shared with me and he was more positive about bisphosphonates than I had heard before. I like to hear different opinions as long as the person is qualified and experienced. We run into different opinions unfortunately. More research is needed!