What is the most effective osteoporosis medication prior to ankle arthroplasty (ankle replacement)?

From the Guidelines

Bisphosphonates, such as alendronate (Fosamax) 70mg weekly or zoledronic acid (Reclast) 5mg IV annually, are the most recommended medications for treating osteoporosis prior to ankle replacement surgery, as they have the most favorable balance of benefits and harms, and are supported by high-certainty evidence 1. These medications should ideally be started 3-6 months before surgery to improve bone density and enhance implant fixation.

• The benefits of bisphosphonates include a reduction in the risk of fractures, particularly vertebral and nonvertebral fractures, as well as hip fractures 1.
• The potential harms of bisphosphonates include mild upper GI symptoms, atypical subtrochanteric fracture, and osteonecrosis of the jaw 1. For patients who cannot tolerate bisphosphonates due to gastrointestinal issues or kidney problems, denosumab (Prolia) 60mg subcutaneously every 6 months is an excellent alternative, as it has been shown to reduce the risk of fractures in postmenopausal females with primary osteoporosis who have contraindications to bisphosphonates 1. Anabolic agents such as teriparatide (Forteo) or abaloparatide (Tymlos) may be considered for severe osteoporosis cases, administered as daily subcutaneous injections for up to 24 months, but they may increase the risk of serious adverse events 1. Regardless of medication choice, calcium supplementation (1000-1200mg daily) and vitamin D (800-1000 IU daily) should be included in the regimen to optimize bone health before ankle replacement surgery. The medication choice should be individualized based on the patient's specific bone density measurements, fracture risk, comorbidities, and potential contraindications.
• Patient preferences and values should also be taken into account when making treatment decisions, as they can impact adherence to medication and overall outcomes 1. Optimizing bone health before ankle replacement is crucial as it reduces the risk of implant loosening, improves osseointegration, and enhances overall surgical outcomes.

From the FDA Drug Label

There is no information in the provided drug labels that directly supports the answer to the question about the best osteoporosis medication prior to ankle replacement. The FDA drug label does not answer the question.

From the Research

Osteoporosis Medications

• The following medications have been shown to prevent spine, nonspine, and hip fractures: alendronate, risedronate, zoledronate, and denosumab 2
• Teriparatide and strontium ranelate have been shown to prevent both spine and nonspine fractures, while raloxifene and ibandronate prevent spine fractures 2

Comparison of Bisphosphonates

• Zoledronic acid has been found to be the most effective in preventing vertebral fracture, nonvertebral fracture, and any fracture, while alendronate or zoledronic acid seem to be the most effective in preventing hip fracture 3
• A network meta-analysis found that zoledronic acid significantly reduced the risk of vertebral fracture compared to other bisphosphonates, including alendronate, clodronate, etidronate, ibandronate, risedronate, and tiludronate 3

Timing of Bisphosphonate Initiation

• Early administration of bisphosphonates after surgery does not appear to delay fracture healing time, either radiologically or clinically 4
• The anti-resorptive efficacy of bisphosphonates given immediately after surgical repair may positively affect the rate of subsequent fractures 4

Denosumab vs Bisphosphonates

• Denosumab has been found to yield higher additional lumbar spine bone mineral density gain compared to bisphosphonates in postmenopausal women with severe osteoporosis after stopping teriparatide therapy 5
• Combination therapy of denosumab and teriparatide may show the most substantial and clinically relevant skeletal benefits to osteoporotic patients 6