Should Prolia (denosumab) be continued or switched to Reclast (zoledronic acid), Forteo (teriparatide), or Evenity (romosozumab) for osteoporosis management?

From the Guidelines

I would recommend continuing Prolia at this time rather than switching to Reclast, Forteo, or Evenity. The patient has shown significant improvement on Prolia therapy with her bone density tests demonstrating a 7.2% improvement in the lumbar spine (T-score improved from -1.9 to -1.3) and a 6.4% improvement in the left hip (T-score improved from -3.1 to -2.8) 1. Most importantly, she has not experienced any fractures while on this medication, which is the primary goal of osteoporosis treatment. Prolia (denosumab) works by inhibiting RANK ligand, which reduces bone resorption and increases bone density.

Since the patient is tolerating the medication well and showing measurable improvement, changing to a different medication is unnecessary at this time. The current regimen of Prolia injections every 6 months, along with daily calcium (1200 mg) and vitamin D (2000 IU) supplementation, appears to be effective for this patient. If the patient were to discontinue Prolia, there would be a risk of rapid bone loss, so maintaining consistent treatment is important.

Key points to consider in this decision include:

• The patient's bone density has improved on Prolia, indicating the medication's effectiveness.
• The patient has not experienced any fractures, which is the primary goal of osteoporosis treatment.
• Prolia has been well-tolerated, with no reported side effects.
• The patient's current regimen includes adequate calcium and vitamin D supplementation, which is essential for bone health.

While Reclast, Forteo, and Evenity are all effective osteoporosis medications, there is no compelling reason to change a successful treatment strategy in this case. According to the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis, denosumab is a recommended treatment option for patients at moderate, high, or very high risk of fracture 1.

In addition, the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults recommend denosumab as an alternative agent for patients intolerant of bisphosphonates or where contraindicated 1. However, since the patient is tolerating Prolia well and showing improvement, switching to a different medication is not necessary at this time. Continuing Prolia is the best course of action to maintain the patient's bone health and prevent fractures.

From the FDA Drug Label

The anabolic effect of EVENITY wanes after 12 monthly doses of therapy. If osteoporosis therapy remains warranted, continued therapy with an anti-resorptive agent should be considered

The patient has been on Prolia shots and has shown improvement in bone density. Continuing Prolia treatment is a viable option as it has shown effectiveness in increasing bone density without fractures.

• The patient's current treatment with Prolia has resulted in a 7.2% improvement at the lumbar spine and 6.4% improvement at the left hip.
• There is no direct information in the provided drug labels that suggests switching to Reclast, Forteo, or Evenity would be more beneficial for this patient at this time.
• Considering the patient's history and current response to Prolia, sticking with the current treatment plan may be the most appropriate course of action 2, 2, 2.

From the Research

Osteoporosis Management

• The patient, Julie, has been diagnosed with osteoporosis and has been on Prolia shots for a couple of years.
• Recent bone density tests have shown improvement in T-scores at the lumbar spine and left hip, indicating effective response to Prolia treatment 3, 4.
• The patient's current treatment plan includes continuing Prolia or switching to Reclast, an annual IV infusion for osteoporosis, for a duration of 3 years.

Treatment Options

• Prolia (denosumab) has been shown to improve bone mineral density and reduce the incidence of new fractures in postmenopausal women and men 3, 4.
• Reclast (zoledronic acid) is another treatment option for osteoporosis, which works by slowing the breakdown of bone, similar to Prolia, but through a different mechanism.
• Other treatment options, such as Forteo (teriparatide) and Evenity (romosozumab), may also be considered, but their effectiveness and safety compared to Prolia and Reclast need to be evaluated 5, 6.

Considerations for Treatment Discontinuation

• Discontinuation of denosumab (Prolia) can lead to a rebound of bone turnover markers and loss of accrued bone mineral density, and may increase the risk of fractures, particularly multiple vertebral fractures 7.
• The decision to discontinue denosumab should be based on individual patient factors, such as bone mineral density, fracture risk, and potential side effects 7.

Comparison of Treatment Options

• A systematic review and network meta-analysis found that denosumab, raloxifene, romosozumab, and teriparatide were all effective in preventing osteoporotic fragility fractures, but their relative effectiveness varied depending on the outcome measured 6.
• Another study found that denosumab was associated with significant benefits in lumbar spine and total hip bone mineral density compared to placebo, but not in reducing vertebral and nonvertebral fractures 5.