Does an 80-year-old female patient taking Prolia (denosumab) require a bone scan, having not had one since initiating treatment over 15 years ago?

From the Guidelines

An 80-year-old female patient taking Prolia (denosumab) does not necessarily require a bone scan, as the American College of Physicians recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women 1. However, considering the patient has been on treatment for over 15 years, it is essential to evaluate the effectiveness of the current treatment and assess the patient's bone health. The American College of Physicians guideline update from 2017 1 provides recommendations for the treatment of low bone density or osteoporosis to prevent fractures in men and women, including the use of denosumab. Some key points to consider in this patient's case include:

• The benefits of treatment with denosumab, including reduction in vertebral and nonvertebral fracture 1
• The potential harms of treatment, such as mild upper GI symptoms and rash/eczema 1
• The importance of regular monitoring of calcium levels and vitamin D status, as denosumab can cause hypocalcemia [not explicitly stated in (1) but relevant to denosumab therapy] Given the patient's age and long-term treatment, it is crucial to weigh the benefits and harms of continuing denosumab therapy and consider alternative treatment options if necessary. Regular monitoring of the patient's overall health, including bone health, is essential to ensure the best possible outcomes and quality of life. In this case, a bone scan may be considered to assess the patient's bone mineral density status and determine if the current treatment remains appropriate, but it is not necessarily required based on the American College of Physicians recommendations 1.

From the Research

Bone Scan Requirement for 80-year-old Female Patient on Prolia (Denosumab)

• The patient has been taking Prolia (denosumab) for over 15 years, and the question arises whether a bone scan is required, given that she has not had one since initiating treatment.
• According to the study 2, denosumab produces a continuous increase in bone mineral density over ten years, associated with a low risk of vertebral and non-vertebral fractures.
• However, the study 2 also mentions that discontinuation of treatment is associated with a severe rebound effect, including a sharp increase in bone turnover markers, loss of the bone density gained, and a risk of nearly 20% of multiple vertebral fractures in postmenopausal women.
• The study 3 evaluated the efficiency and safety of long-term Prolia therapy in patients with postmenopausal osteoporosis and found that denosumab was effective in increasing bone mineral density and reducing bone resorption markers.
• The study 4 reviewed the use of denosumab in the treatment of postmenopausal osteoporosis and found that it reduced the risk of vertebral, nonvertebral, and hip fractures compared with placebo over 3 years.
• The study 5 also found that denosumab reduced the risk of vertebral, nonvertebral, and hip fractures and increased bone mineral density across skeletal sites versus placebo.
• However, the study 6 reported a case of an impending atypical femoral fracture in a patient with breast cancer and bone metastases receiving long-term denosumab, highlighting the potential risk of atypical femoral fractures in patients on long-term denosumab treatment.
• Given the patient's long-term use of denosumab and the potential risks associated with discontinuation of treatment, a bone scan may be necessary to assess her current bone health and risk of fractures 2, 3, 4, 5.
• Additionally, the patient's age and long-term use of denosumab increase the risk of atypical femoral fractures, making a bone scan a necessary diagnostic tool to monitor her condition 6.