What is the recommended treatment for a patient with osteoporosis, a high FRAX (Fracture Risk Assessment Tool) score indicating 18% risk of hip fracture and 40% risk of major osteoporotic fracture, and upcoming lumbar surgery, considering Evenity (romosozumab) as a potential option?

From the Guidelines

For a patient with osteoporosis, high FRAX score (18% hip fracture risk, 40% major osteoporotic fracture risk), and upcoming lumbar surgery, an anabolic agent like romosozumab (Evenity) is the most appropriate first-line treatment, as it rapidly increases bone mineral density and reduces fracture risk 1. Given the patient's high fracture risk, it is essential to initiate treatment as soon as possible, ideally at least 1-2 months before surgery to improve bone quality.

• The treatment regimen should include romosozumab administered as a 210mg subcutaneous injection once monthly for 12 months.
• After 12 months, the patient should be transitioned to an antiresorptive agent, such as alendronate (70mg weekly) or denosumab (60mg subcutaneously every 6 months), for long-term maintenance.
• Before starting treatment, the patient's calcium and vitamin D levels should be assessed and supplemented if deficient, typically with 1000-1200mg calcium and 800-1000 IU vitamin D daily.
• Regular monitoring with bone mineral density testing is recommended after 12 months when transitioning to maintenance therapy. The use of romosozumab is supported by recent guidelines, which recommend anabolic agents for patients at very high risk of fracture, as they provide faster and greater BMD improvements compared to antiresorptive agents alone 1.
• The patient's high FRAX score and upcoming lumbar surgery make it crucial to prioritize treatments that can rapidly improve bone quality and reduce fracture risk.
• Romosozumab's dual mechanism of increasing bone formation and decreasing bone resorption makes it an ideal choice for this patient. Key considerations in the management of this patient include:
• The importance of prompt treatment initiation to reduce fracture risk before surgery
• The need for regular monitoring and adjustment of treatment as necessary to ensure optimal bone health
• The consideration of potential side effects and interactions with other medications when selecting a treatment regimen.

From the FDA Drug Label

1. 1 Treatment of Postmenopausal Women with Osteoporosis at High Risk for Fracture EVENITY is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy.

The patient in question has a high FRAX score, indicating an 18% risk of hip fracture and a 40% risk of major osteoporotic fracture, which suggests that they are at high risk for fracture. Given the patient's upcoming lumbar surgery and high risk of fracture, Evenity (romosozumab) may be a suitable treatment option to reduce the risk of fracture. Key points to consider:

• The patient's FRAX score indicates a high risk of fracture
• The patient has an upcoming lumbar surgery, which may increase the risk of fracture
• Evenity (romosozumab) is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture
• The treatment duration for Evenity is limited to 12 monthly doses 2

From the Research

Patient Background

• The patient has osteoporosis with a high FRAX score, indicating an 18% risk of hip fracture and 40% risk of major osteoporotic fracture.
• The patient is scheduled for lumbar surgery.

Treatment Considerations

• Evenity (romosozumab) is a potential treatment option for the patient, as it has been shown to reduce vertebral and clinical fracture risk in postmenopausal women with osteoporosis 3, 4, 5.
• Romosozumab has a dual effect on bone, increasing bone formation and decreasing bone resorption, which may be beneficial for patients with high fracture risk 3, 5.
• The treatment is generally well-tolerated, but may be associated with increased risks of hypersensitivity and injection site reactions 6.

Recommended Treatment

• Based on the patient's high FRAX score and upcoming lumbar surgery, treatment with Evenity (romosozumab) may be considered to reduce the risk of fractures 3, 4, 5.
• The patient's bone mineral density (BMD) and fracture risk should be closely monitored during treatment with romosozumab 3, 7.
• It is essential to weigh the benefits and risks of romosozumab treatment for the patient, considering their individual medical history and fracture risk 4, 6.

Key Points to Consider

• Romosozumab is approved for the treatment of osteoporosis in postmenopausal women at high risk of fracture 3, 4.
• The treatment has been shown to increase BMD and reduce fracture risk in clinical trials 3, 5, 7.
• Close monitoring of the patient's response to treatment and potential adverse events is necessary 7, 6.