What is the next recommended treatment for a patient with a history of osteonecrosis of the jaw (ONJ) on Ibandronate (ibandronate) after two years on Forteo (teriparatide) without fractures?

Next Treatment Recommendation After Forteo for Patient with History of ONJ on Ibandronate

Denosumab (60 mg subcutaneously every 6 months) is the recommended next treatment for a patient with history of ONJ on ibandronate after completing two years of teriparatide (Forteo) therapy. 1

Rationale for Denosumab Selection

• Denosumab is considered the most effective treatment option for patients with a history of ONJ who have completed teriparatide therapy, as it has a different mechanism of action than bisphosphonates 1
• Denosumab has a shorter half-life than bisphosphonates, which may be advantageous in patients with prior ONJ, as temporary discontinuation could potentially enhance ONJ resolution if needed 1
• Denosumab 60 mg every 6 months has been shown to reduce fractures by 50% compared to placebo, providing strong evidence for bone health preservation 1

Important Considerations for Denosumab Therapy

Pre-Treatment Requirements

• Baseline dental examination is mandatory before initiating denosumab to assess ONJ risk 2
• Serum calcium levels must be measured and any hypocalcemia corrected before starting treatment 2
• Vitamin D status should be evaluated to ensure adequate levels prior to initiation 2

During Treatment

• Regular monitoring of serum calcium is necessary, especially after the first few doses 2
• Calcium supplementation (500-1000 mg/day) and vitamin D supplementation are required during treatment 2
• Maintain excellent oral hygiene and schedule regular dental check-ups every 6 months 3

Contraindications and Cautions

• Avoid invasive dental procedures when possible during denosumab therapy 3
• If dental procedures are necessary, consider the timing carefully in relation to denosumab administration 3
• Hypocalcemia is a contraindication and must be corrected before starting denosumab 2

Alternative Options

• Romosozumab could be considered, but there are concerns about increased risk of myocardial infarction, stroke, and death 1
• Raloxifene is generally not recommended due to increased risk of venous thromboembolism and fatal stroke 1
• Restarting bisphosphonates (including ibandronate) is not advised given the patient's history of ONJ 4

ONJ Risk Considerations

• The incidence of ONJ with denosumab in osteoporosis patients is estimated at 28.3 per 10,000 patient-years compared to 4.5 with bisphosphonates 4
• Previous bisphosphonate therapy (like ibandronate in this case) before switching to denosumab may increase ONJ risk 4
• Regular dental care and attention to oral health is essential to minimize ONJ risk 1

Monitoring Recommendations

• Measure bone mineral density (BMD) every 1-2 years during treatment 1
• Monitor serum calcium before each denosumab injection 2
• Schedule dental follow-up every 6-8 weeks if any dental procedures are performed until complete mucosal healing occurs 3

Duration of Therapy

• Denosumab is typically administered for up to 5 years 1
• Abrupt discontinuation should be avoided as it can lead to rebound bone loss and increased fracture risk 2
• If ONJ develops during treatment, temporary discontinuation may be considered, weighing the risk against potential skeletal-related events 1