Can Evenity (romosozumab‑aqqg) cause hair loss in a patient being treated with the standard 210 mg subcutaneous injection once monthly for up to 12 months?

Can Evenity Cause Hair Loss?

Hair loss is not documented as a recognized adverse effect of Evenity (romosozumab) in major clinical guidelines or clinical trials. The 2023 American College of Physicians guidelines on osteoporosis treatment, which extensively reviewed romosozumab safety data, do not list hair loss among the adverse events reported in randomized controlled trials 1.

Evidence from Clinical Trials

The pivotal phase III trials (FRAME and ARCH) that led to romosozumab's approval documented specific adverse events but did not identify hair loss as a treatment-related side effect 2. The safety profile from these trials showed:

• No difference in serious adverse events compared to placebo (moderate certainty evidence) 1
• No difference in withdrawals due to adverse events compared to placebo (low certainty evidence) 1
• Increased cardiovascular risk compared to alendronate (hazard ratio 1.9) was the primary safety concern identified 1

The comprehensive safety reviews in multiple publications describing romosozumab's approval and clinical characteristics do not mention alopecia or hair loss among documented adverse effects 3, 4, 2, 5, 6.

Differential Diagnosis to Consider

If a patient on Evenity reports hair loss, the following alternative causes should be systematically evaluated:

Laboratory Assessment

• Thyroid function tests (TSH, free T4) to rule out thyroid dysfunction 1
• Iron stores (ferritin) to assess for iron deficiency 1
• Vitamin D levels to identify deficiency 1
• Zinc levels to evaluate for nutritional deficiency 1

Other Considerations

• Underlying osteoporosis-related factors: The disease itself or associated conditions may contribute to hair changes
• Concomitant medications: Review all medications the patient is taking, as many drugs can cause hair loss
• Age-related changes: Postmenopausal women (the primary population for romosozumab) commonly experience female-pattern hair loss independent of medication use 1
• Nutritional status: Assess for overall nutritional deficiencies, particularly in elderly patients

Management Approach

If hair loss occurs during Evenity treatment, do not attribute it to romosozumab without excluding other causes. The medication should not be discontinued based on hair loss alone, given the lack of evidence linking the two and the significant fracture reduction benefits demonstrated in clinical trials 1, 2.

Recommended Steps:

1. Complete laboratory evaluation as outlined above to identify correctable causes 1
2. Correct any identified deficiencies (thyroid hormone replacement, iron supplementation, vitamin D repletion, zinc supplementation as appropriate) 1
3. Consider topical minoxidil 5% to stimulate hair regrowth if no reversible cause is identified 1
4. Biotin supplementation (2.5 mg daily) may be considered, though evidence for efficacy is limited 1
5. Dermatology referral if hair loss is severe, progressive, or does not respond to initial interventions

Important Caveats

• The absence of hair loss in clinical trial safety data does not absolutely exclude the possibility of rare idiosyncratic reactions, but it makes a causal relationship highly unlikely
• Postmenopausal women have multiple risk factors for hair thinning unrelated to osteoporosis medications
• Do not discontinue Evenity without medical guidance, as the fracture reduction benefits (4 fewer clinical vertebral fractures per 1000 patients, 13 fewer radiographic vertebral fractures per 1000 patients) are substantial 1
• The 12-month treatment duration is finite, and any medication-related effects would be expected to resolve after completion of therapy 3