Initiating Prolia in a 70-Year-Old Male with Humeral Fracture Without DEXA Results
Prolia (denosumab) can be initiated in a 70-year-old male with a fracture of the surgical neck of the humerus without waiting for DEXA results, as this patient already has a documented fragility fracture which indicates high fracture risk.
Rationale for Treatment Without DEXA
Risk Factors Supporting Immediate Treatment
- Age over 70 years: Advanced age is a high-risk factor for osteoporotic fracture 1
- Existing fragility fracture: A fracture of the surgical neck of the humerus in this context is considered a fragility fracture
- Male gender with fracture: Men with osteoporotic fractures have higher mortality rates than women 1
Guideline Support
- According to EULAR/EFORT recommendations, each patient aged 50 years and over with a recent fracture should be evaluated systematically for the risk of subsequent fractures 1
- The presence of a fragility fracture alone is sufficient to diagnose osteoporosis and initiate treatment without necessarily requiring DEXA confirmation 1
- Key risk factors for low BMD-mediated fracture include increased age (>70 years) and previous osteoporotic fracture 1
Treatment Protocol
Dosing and Administration
- Prolia (denosumab) 60 mg subcutaneously every 6 months
- Ensure patient receives adequate calcium and vitamin D supplementation before and during treatment
Monitoring
- Although treatment can begin without DEXA, a baseline DEXA should still be obtained when possible to:
- Establish a reference point for future monitoring
- Help determine treatment duration
- Assess treatment efficacy at follow-up
Important Considerations
Benefits of Early Treatment
- Immediate treatment reduces the risk of subsequent fractures
- The risk of subsequent fracture is highest in the immediate post-fracture period 1
- Delaying treatment increases the risk of additional fractures
Cautions with Denosumab
- Risk upon discontinuation: Denosumab discontinuation leads to rapid bone loss and increased risk of multiple vertebral fractures 2, 3
- Need for sequential therapy: If denosumab is discontinued, transition to an alternative antiresorptive treatment is necessary 2
- Adherence importance: Delayed injections beyond 16 weeks are associated with increased vertebral fracture risk 4
Follow-up Recommendations
- Obtain DEXA scan when feasible (not required before initiating treatment)
- Consider vertebral fracture assessment (VFA) or spinal x-rays to identify any subclinical vertebral fractures 1
- Evaluate for secondary causes of osteoporosis
- Ensure adequate calcium and vitamin D intake
- Encourage weight-bearing exercise and fall prevention strategies
- Schedule follow-up for next denosumab injection in exactly 6 months
Conclusion
The presence of a fragility fracture in a 70-year-old male is sufficient evidence of osteoporosis to warrant immediate treatment with denosumab without waiting for DEXA results. This approach is supported by guidelines and will help prevent the high risk of subsequent fractures in this high-risk patient.