Should an elderly female with osteoporosis (OP) continue or hold Prolia (denosumab) before undergoing arthroscopic back surgery?

Should Prolia Be Continued or Held Before Arthroscopic Back Surgery?

Continue Prolia (denosumab) through the perioperative period for arthroscopic back surgery—there is no evidence-based indication to hold this medication, and discontinuation creates significant risk of rebound vertebral fractures. 1, 2

Critical Safety Concern: Do Not Discontinue Denosumab

• Stopping Prolia leads to rapid rebound bone turnover with increased risk of multiple vertebral fractures, typically occurring 7-43 months after the last injection, with mean onset at 17 months 2
• In clinical trials, 6% of women who discontinued Prolia developed new vertebral fractures, and 3% developed multiple new vertebral fractures 2
• Prior vertebral fracture is a predictor of multiple vertebral fractures after discontinuation 2
• If denosumab must ever be stopped, transition to a bisphosphonate beginning 6-7 months after the last dose is mandatory to prevent rebound bone loss 1, 3

Perioperative Management Rationale

No Contraindication for Surgery

• There is no guideline or FDA recommendation to hold denosumab before elective orthopedic surgery, including spinal procedures 2
• Denosumab is administered subcutaneously every 6 months, so timing surgery around the dosing schedule is not typically necessary 2
• The drug does not increase surgical bleeding risk or impair wound healing in the manner that anticoagulants or immunosuppressants might 2

Potential Benefits for Spinal Surgery

• Denosumab may actually benefit surgical outcomes in osteoporotic patients undergoing spinal instrumentation 1
• In osteoporotic patients undergoing instrumented fusion, teriparatide showed 7% screw loosening rate versus 13-15% in bisphosphonate or control groups, suggesting bone quality matters for hardware fixation 1
• While this evidence is for teriparatide (an anabolic agent), denosumab's potent antiresorptive effects maintain bone quality that could similarly support surgical hardware 1

Infection Risk Consideration

• Denosumab inhibits RANKL, which is expressed on activated T and B lymphocytes, theoretically increasing infection risk 2
• In the pivotal 3-year trial, serious infections occurred in 4.0% of Prolia patients versus 3.3% of placebo patients 2
• Skin infections (cellulitis, erysipelas) requiring hospitalization occurred in 0.4% of Prolia patients versus <0.1% of placebo patients 2
• However, this modest infection risk does not warrant discontinuation for surgery, as the rebound fracture risk from stopping far outweighs any theoretical infection benefit 2

Practical Management Algorithm

Timing Considerations

• If the patient is due for her next Prolia injection within 1-2 months of surgery: Administer the injection as scheduled; do not delay 2
• If surgery falls mid-cycle between injections: Proceed with surgery without holding the medication 2
• The 6-month dosing interval provides flexibility—there is no "washout period" needed 2

Perioperative Monitoring

• Ensure adequate calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation perioperatively 4, 2
• Monitor serum calcium levels postoperatively, particularly if the patient has impaired renal function (creatinine clearance <30 mL/min), as hypocalcemia risk increases 2
• In patients with creatinine clearance <30 mL/min, 29% experienced calcium levels <7.5 mg/dL or symptomatic hypocalcemia in clinical studies 2

Post-Surgical Continuation

• Resume or continue the regular 6-month Prolia injection schedule without interruption 4
• Do not skip doses due to surgery—maintaining continuous therapy is essential to prevent rebound bone loss 2

Common Pitfall to Avoid

The most critical error would be discontinuing Prolia "to be safe" before surgery—this creates far greater harm through rebound vertebral fractures than any theoretical perioperative risk. Unlike anticoagulants or immunosuppressants that require perioperative management, osteoporosis medications like denosumab should continue uninterrupted unless there is a specific contraindication (which routine arthroscopic back surgery is not). 1, 2