From the Guidelines
For a 68-year-old female with worsening osteoporosis on Prolia (denosumab) who is experiencing insurance coverage issues, the most appropriate alternative treatment option is oral bisphosphonates, such as alendronate (Fosamax) 70mg once weekly, as recommended by the American College of Physicians 1. This recommendation is based on high-quality evidence that shows pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab reduces the risk for hip and vertebral fractures in women with known osteoporosis. Some key points to consider when switching medications include:
- Oral bisphosphonates are the most cost-effective first-line alternatives and work by inhibiting bone resorption, and are generally well-tolerated.
- If oral medications aren't suitable, zoledronic acid (Reclast), an annual IV infusion, could be considered, though it may also have cost implications.
- For patients who cannot tolerate bisphosphonates, raloxifene (Evista) 60mg daily is an option, particularly beneficial for postmenopausal women as it also reduces breast cancer risk.
- Teriparatide (Forteo) or abaloparatide (Tymlos) are daily self-injections that build new bone but are typically reserved for severe cases due to their cost.
- Regardless of medication choice, the patient should continue calcium supplementation (1000-1200mg daily) and vitamin D (800-1000 IU daily), along with weight-bearing exercises and fall prevention strategies, as recommended by the American College of Rheumatology 1. Given her worsening bone density despite Prolia treatment, a comprehensive evaluation of treatment effectiveness, adherence, and potential secondary causes of bone loss should be conducted before switching medications.
From the Research
Treatment Options for Osteoporosis
The patient is currently on Prolia injections for osteoporosis, but due to increased cost, they are seeking alternative treatment options.
- Denosumab (Prolia) is a fully human monoclonal antibody against the receptor activator of the nuclear factor kappaB ligand, which has been shown to improve bone mineral density and reduce the incidence of new fractures in postmenopausal women and men 2.
- Other treatment options for osteoporosis include bisphosphonates (alendronate, risedronate, zoledronic acid, ibandronate), osteoanabolic agents (teriparatide, abaloparatide, romosozumab), and selective estrogen receptor modulators (SERMs) 3, 4.
- The selection of osteoporosis treatment should be individualized and based on a variety of factors, including underlying fracture risk, medical comorbidities, medication burden, as well as fracture risk reduction profiles, modes of administration, and side effects of treatment options 3.
Discontinuation of Denosumab
- Discontinuation of denosumab may be considered in patients who have been treated for a certain period, but close monitoring is suggested due to the possibility of rebound fractures 5.
- The optimal duration of use of denosumab has not been determined, and further study is needed to address questions regarding treatment duration and discontinuation 2, 5.
Comparison of Treatment Options
- Denosumab has been compared to bisphosphonates, SERMs, and placebo in terms of effectiveness and safety, and has been shown to be effective in increasing bone mineral density and reducing the incidence of fractures 6.
- Economic evaluations have shown that denosumab can be cost-effective in certain populations, such as postmenopausal women and older men with osteoporosis 4.
- However, the cost-effectiveness of denosumab compared to other treatment options may vary depending on the population and the specific treatment regimen 4.