What is the preferred initial treatment for osteoporosis in a 67-year-old female with a history of ductal carcinoma in situ (DCIS) of the breast, status post lumpectomy, chemotherapy, and radiation?

From the Guidelines

The preferred initial treatment for osteoporosis in a 67-year-old female with a history of ductal carcinoma in situ (DCIS) of the breast who has undergone lumpectomy, chemotherapy, and radiation is a bisphosphonate, such as alendronate (Fosamax) 70 mg orally once weekly, as it is generally well-tolerated and effectively reduces fracture risk by inhibiting bone resorption 1. Given her breast cancer history, selective estrogen receptor modulators (SERMs) like raloxifene should be avoided as they may interact with breast cancer treatments, and the use of estrogen, progesterone, or SERMs to treat osteoporosis or osteopenia in women with breast cancer is discouraged 1. The patient should also take calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplements to support bone health, as adequate calcium and vitamin intake should be part of fracture prevention in all postmenopausal females with low bone mass or osteoporosis 1. Key considerations for treatment include:

• The bisphosphonate should be taken first thing in the morning with a full glass of water, and the patient should remain upright for at least 30 minutes afterward to prevent esophageal irritation.
• Treatment effectiveness should be monitored with bone mineral density testing every 1-2 years.
• If bisphosphonates are contraindicated or not tolerated, denosumab (Prolia) 60 mg subcutaneously every 6 months could be considered as an alternative.
• Weight-bearing exercise and fall prevention strategies are also important components of comprehensive osteoporosis management. It is essential to individualize treatment selection based on comorbidities and concomitant medications associated with higher risk for falls/fractures, especially in older postmenopausal females with primary osteoporosis who are at increased risk for falls and other adverse events due to polypharmacy or drug interactions 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Osteoporosis

• Denosumab is a human monoclonal antibody that targets the key bone resorption mediator RANKL, and is approved for the treatment of postmenopausal osteoporosis in women at increased/high risk of fracture or failure/intolerance of other osteoporosis therapies 2, 3, 4.
• Denosumab has been shown to reduce the risk of vertebral, nonvertebral, and hip fractures, and increase bone mineral density (BMD) in postmenopausal women with osteoporosis 2, 3, 4, 5, 6.
• The drug is administered via subcutaneous injection once every 6 months, which may be a preferred method of administration and may improve adherence to treatment compared with other osteoporosis treatments 3, 4, 6.

Preferred Initial Treatment

• Although bisphosphonates are typically preferred as initial therapy for osteoporosis, denosumab could be used as initial therapy in select patients at high risk for fracture, including older patients who have difficulty with the dosing requirements of oral bisphosphonates, patients who are intolerant of or unresponsive to other therapies, and in those with impaired renal function 5.
• In the case of a 67-year-old female with a history of ductal carcinoma in situ (DCIS) of the breast, status post lumpectomy, chemotherapy, and radiation, denosumab may be considered as a preferred initial treatment option due to its efficacy in reducing fracture risk and improving BMD, as well as its convenient administration schedule 2, 3, 4, 5, 6.

Considerations

• The potential for multiple vertebral fractures to occur after discontinuation of denosumab requires consideration of subsequent management options 2.
• Safety concerns with denosumab include infections, cancer, skin reactions, cardiovascular disease, hypocalcemia, osteonecrosis of the jaw, and atypical femur fractures 5.