Should I continue Prolia (denosumab) after a fragility fracture?

Continuing Denosumab After a Fragility Fracture

Yes, you should continue Prolia (denosumab) after experiencing a fragility fracture, as it remains an effective treatment option for reducing subsequent fracture risk in patients with established osteoporosis. 1

Rationale for Continuing Treatment

Experiencing a fragility fracture while on denosumab does not indicate treatment failure, but rather highlights the need for:

1. Reassessment of fracture risk
2. Evaluation of treatment adherence
3. Consideration of treatment optimization

Evidence Supporting Continued Treatment

• High-quality evidence shows that denosumab reduces the risk of vertebral, non-vertebral, and hip fractures in patients with osteoporosis 1
• Denosumab has been shown to reduce secondary fracture risk by 39% in patients with prior fragility fractures 2
• The 2022 American College of Rheumatology guidelines specifically recommend continuing denosumab in patients who remain at high risk of fracture (including those with a history of fragility fracture) 1

Treatment Algorithm After Fragility Fracture

Step 1: Reassess Fracture Risk

• Confirm adherence to proper dosing schedule (every 6 months)
• Delayed dosing beyond 16 weeks increases vertebral fracture risk by nearly 4-fold 3
• Evaluate bone mineral density (BMD) with DXA scan
• Consider vertebral fracture assessment (VFA) or spinal x-rays

Step 2: Optimize Current Treatment

• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
• Address modifiable risk factors (smoking, alcohol, fall risk)
• Verify proper administration technique if self-injecting

Step 3: Treatment Decision

For patients who experienced a fragility fracture while on denosumab:

1. If fracture occurred with proper adherence to denosumab:

   • Consider adding or switching to an anabolic agent (PTH/PTHrP analog) 1
   • For very high-risk patients, anabolic agents are conditionally recommended over antiresorptive agents like denosumab 1

2. If fracture occurred with delayed or missed doses:

   • Continue denosumab with strict adherence to 6-month dosing schedule
   • Implement reminder systems to prevent delays

Important Considerations

Risk of Discontinuation

• Never abruptly discontinue denosumab - this causes rapid bone loss and increased risk of multiple vertebral fractures 4
• If denosumab must be discontinued, sequential therapy with a bisphosphonate is strongly recommended 1
• Bisphosphonate should be started 6-7 months after the last denosumab dose 1

Long-term Management

• For patients who remain at high fracture risk (T-score ≤-2.5 or history of fragility fracture), continuing denosumab beyond 5 years is appropriate 1
• Regular monitoring of BMD is recommended to assess treatment response

Common Pitfalls to Avoid

1. Discontinuing treatment after a fracture - this significantly increases risk of subsequent fractures, especially vertebral fractures
2. Delaying subsequent doses - maintaining the strict 6-month dosing schedule is critical
3. Inadequate calcium/vitamin D supplementation - these are essential co-therapies with denosumab
4. Failing to consider combination or sequential therapy - for very high-risk patients, anabolic therapy followed by antiresorptive therapy may be more effective

In conclusion, experiencing a fragility fracture while on denosumab is not a reason to discontinue therapy but rather indicates the need for optimization of treatment and consideration of additional or alternative osteoporosis medications based on individual fracture risk assessment.