Would switching from alendronate (Fosamax) weekly to denosumab (Jubbonti is not a recognized medication, assuming denosumab was intended, also known as Prolia) be better for osteoporosis (OP) management in an elderly patient in long-term care (LTC)?

From the Guidelines

Switching from alendronate to denosumab may be beneficial for elderly patients with osteoporosis in long-term care, as denosumab has been shown to reduce the risk of hip and vertebral fractures in women with known osteoporosis, according to the American College of Physicians guideline update 1. When considering the management of osteoporosis in elderly patients, it is essential to prioritize treatments that have been proven to reduce fracture risk. Denosumab, a monoclonal antibody that inhibits osteoclast formation, has been demonstrated to be effective in reducing vertebral, nonvertebral, and hip fractures in patients with osteoporosis 1.

Key Considerations

• Denosumab has a strong recommendation and high-quality evidence for reducing the risk of hip and vertebral fractures in women with known osteoporosis 1.
• The treatment regimen for denosumab is typically 60 mg subcutaneously every 6 months.
• Important considerations include the potential for mild upper GI symptoms and rash/eczema as adverse events, as well as the need for ongoing treatment to maintain bone density gains.
• The American College of Physicians recommends offering pharmacologic treatment with denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis, making it a viable option for elderly patients in long-term care 1.

Patient-Specific Factors

• When deciding whether to switch from alendronate to denosumab, clinicians should consider individual patient factors, such as fracture risk profile, benefits, harms, and costs of medications.
• For elderly LTC patients with very high fracture risk, severe osteoporosis, or those who have had fractures despite alendronate therapy, denosumab could provide better protection.
• Clinicians should discuss patient preferences and weigh the potential benefits and harms of treatment, including the potential for adverse events and the need for ongoing injections.

From the Research

Osteoporosis Management

• Switching from alendronate (Fosamax) weekly to denosumab (Prolia) for osteoporosis (OP) management in an elderly patient in long-term care (LTC) may be considered based on the patient's individual needs and medical history.
• A study comparing once-weekly alendronate 70 mg and once-daily alendronate 10 mg found that patients preferred the once-weekly dosing regimen due to its convenience and potential for better long-term compliance 2.
• However, when considering switching to denosumab, it is essential to note that denosumab is a different class of medication, and its efficacy and safety profile may vary compared to alendronate.
• Research suggests that initiating treatment with an osteoanabolic agent followed by an antiresorptive, such as denosumab, may be an optimal treatment sequence for patients with severe osteoporosis 3.
• Additionally, a study found that alendronate preserves bone accrued during administration of denosumab, highlighting the potential benefits of sequential therapy 4.

Comparison of Alendronate and Denosumab

• Alendronate has been shown to be effective in preventing collapse of the femoral head in adult patients with nontraumatic osteonecrosis, although the evidence is not strong enough to support its application in this patient population 5.
• Denosumab, on the other hand, has been found to be effective in reducing the risk of vertebral fractures in postmenopausal women with osteoporosis, including those with mild-to-moderate chronic kidney disease 6.
• The safety profile of denosumab has been found to be similar across different levels of kidney function, making it a potential treatment option for patients with osteoporosis and kidney disease 6.

Considerations for Elderly Patients in Long-Term Care

• When considering switching an elderly patient in LTC from alendronate to denosumab, it is crucial to weigh the potential benefits and risks of each medication, taking into account the patient's individual needs, medical history, and kidney function.
• The decision to switch medications should be made in consultation with a healthcare professional, considering the latest clinical guidelines and evidence-based research 3, 4, 6.