From the Guidelines
To switch a patient from Pralia (denosumab) to an oral bisphosphonate before a holiday, start the oral bisphosphonate within one month after the last scheduled Pralia injection, with alendronate prescribed at 70 mg once weekly or risedronate at 35 mg once weekly, as these dosages are supported by the most recent guidelines 1. The oral bisphosphonate should be taken on an empty stomach with a full glass of water, and the patient should remain upright for at least 30 minutes afterward. This timing is crucial because denosumab's effects are reversible, and bone turnover can rapidly increase when the drug is discontinued, potentially leading to rebound bone loss or vertebral fractures, as noted in studies on bone health in cancer patients 1. Starting the bisphosphonate promptly helps maintain bone density protection. Patients should be counseled about proper administration of oral bisphosphonates, including taking them first thing in the morning and avoiding food, other medications, and beverages (except water) for at least 30 minutes after dosing, to minimize gastrointestinal side effects as discussed in the context of bone health and cancer care 1. Calcium and vitamin D supplementation should be continued during this transition to support bone health. Monitor the patient for potential side effects of bisphosphonates, including gastrointestinal irritation, and consider bone turnover markers or bone mineral density testing to ensure effective treatment, aligning with recommendations for managing bone health in patients with cancer 1. Key considerations include the patient's ability to tolerate oral bisphosphonates, potential renal impairment, and the risk of osteonecrosis of the jaw, although the latter is more commonly associated with intravenous bisphosphonate use 1. By following these guidelines and considering the patient's individual needs and medical history, the transition from denosumab to an oral bisphosphonate can be managed effectively to maintain bone health and minimize risks.
From the Research
Switching from Pralia (Denosumab) to Oral Bisphosphonates
To switch a patient from Pralia (denosumab) to an oral bisphosphonate, such as alendronate or risedronate, consider the following steps:
- Assess the patient's fracture risk and bone mineral density (BMD) to determine the best course of treatment 2, 3.
- Consider the patient's previous treatment history and response to denosumab or other osteoporosis medications 4, 5.
- Choose an oral bisphosphonate that is appropriate for the patient's condition, such as alendronate or risedronate, which have been shown to reduce the risk of vertebral and non-vertebral fractures in postmenopausal women with osteoporosis 6.
Key Considerations
- When discontinuing denosumab, close monitoring is suggested due to the possibility of rebound fractures 2.
- A "drug holiday" from bisphosphonates can be considered after a certain treatment period, but this approach should not be implemented for denosumab, estrogen, SERMs, or teriparatide 3.
- Transitioning from a bisphosphonate to denosumab has been shown to be safe and effective in improving BMD, but the reverse transition (from denosumab to a bisphosphonate) may require careful consideration of the patient's individual needs and response to treatment 5.
Oral Bisphosphonate Options
- Alendronate: has been shown to reduce the risk of vertebral and non-vertebral fractures in postmenopausal women with osteoporosis, and can be considered for patients who have been treated with denosumab 4, 6.
- Risedronate: has also been shown to reduce the risk of vertebral and non-vertebral fractures, and can be considered as an alternative to alendronate 4, 6.