As a clinical pharmacist, I do my best to stay up to date in all areas of pharmacy. I enjoy it and it helps me make sure you are prepared for your board exams! There’s always something to learn and today is no different. Anecdotally, I’ve felt over the last couple of years that I have been seeing less use of denosumab (Prolia) compared to previous years. Denosumab is an osteoporosis agent and is used as an alternative to bisphosphonates. There is evidence that denosumab discontinuation can increase the risk of vertebral fractures.
In one retrospective study, sixty vertebral fractures were encountered in 15 women when denosumab was discontinued.
In a different Cohort, delaying denosumab injections led to an increase in vertebral fractures.
Denosumab has definitely shown efficacy in managing osteoporosis. If we have contraindications to other agents like oral bisphosphonates, it remains a reasonable alternative. Candid discussions need to be had with patients regarding this risk when stopping denosumab as it seems fairly clear from these two pieces of literature that denosumab discontinuation can lead to increased rebound vertebral fractures.
Here are a few patient populations where I would be very hesitant about using denosumab due to discontinuation and increased vertebral fractures.
- Patients with a history of poor follow-up and poor medication adherence
- Patients at low to moderate risk of fracture who may not want or need lifelong therapy
- Patients looking to minimize the use of long-term medication
Are you seeing denosumab used in your practice? Do you not recommend this medication because of the vertebral risks upon discontinuation?
I think the point that discontinuation of denosumab lead to vertebral fracture is more associated with long use (over 5 years) than 1 year , even though the anabolic effect of its use appears after 1-2 years .
Thanks for letting me speak
Thanks for sharing.
1/ Is the longer patient is on Prolia, the greater rebound effect would be?
2/ For those need to stop (cost?), is it beneficial to restart them on bisphosphonates?
1. I don’t know that answer off hand, but logically, that would make sense to me
2. A lot of clinical factors will likely go into that decision.