Prolia (denosumab) vs Zometa (zolendronic acid) for bisphos-refractory (or intolerant) Osteoporosis

[DrMetal]

Prolia (denosumab) vs Zometa (zolendronic acid) for bisphos-refractory (or intolerant) Osteoporosis:

Which do you prefer?

Prolia is a q 6mo injection, Zometa a q12month infusion. Patients have to be compliant with both, and it's life-long therapy. Though, I've heard that the consequences of mal-compliance with Prolia are more severe, more prone to fractures if you stop the Prolia. True? Thoughts?

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[rokshana]

Prolia (denosumab) vs Zometa (zolendronic acid) for bisphos-refractory (or intolerant) Osteoporosis:

Which do you prefer?

Prolia is a q 6mo injection, Zometa a q12month infusion. Patients have to be compliant with both, and it's life-long therapy. Though, I've heard that the consequences of mal-compliance with Prolia are more severe, more prone to fractures if you stop the Prolia. True? Thoughts?

Zometa is the bisphosphonate dosing (5 mg)for cancer…Reclast (4mg)is the dosing for osteoporosis . Reclast can generally be used for 3-5 years before needing to consider drug holiday since there is an increase risk of atypical femur fractures and ONJ… whether that is real or not is debatable.
Prolia… ugh hate prolia and avoid it unless absolutely necessary. Because once you start prolia, it is effectively lifelong… the risks for decrease in bmd in the next 18 months after d/c is significant and risk for fracture increases. Studies show that there is less improvement in bmd when prolia is given and then switched to anabolics like evenity, forteo, or tymlos vs the other way around.

if not improving on PO bisphosphonates, then would try reclast… if dxa is > -3 and not actively fracturing… if < -3 and high risk for fractures, would use anabolics first, then transition to a BP, either Reclast or fosamax… but depends on bmd and fracture risks…the fda just recently lifted the 2 year limit on forteo, so can conceivably use anabolics for a number of years now.

Will use prolia if renal failure and dont have any other choice…or in men with osteoporosis since forteo only anabolic i can use in men…though now may be able to use for longer than 2 years .

 

[DrMetal]

Zometa is the bisphosphonate dosing (5 mg)for cancer…Reclast (4mg)is the dosing for osteoporosis . Reclast can generally be used for 3-5 years before needing to consider drug holiday since there is an increase risk of atypical femur fractures and ONJ… whether that is real or not is debatable.
Prolia… ugh hate prolia and avoid it unless absolutely necessary. Because once you start prolia, it is effectively lifelong… the risks for decrease in bmd in the next 18 months after d/c is significant and risk for fracture increases. Studies show that there is less improvement in bmd when prolia is given and then switched to anabolics like evenity, forteo, or tymlos vs the other way around.

if not improving on PO bisphosphonates, then would try reclast… if dxa is > -3 and not actively fracturing… if < -3 and high risk for fractures, would use anabolics first, then transition to a BP, either Reclast or fosamax… but depends on bmd and fracture risks…the fda just recently lifted the 2 year limit on forteo, so can conceivably use anabolics for a number of years now.

Will use prolia if renal failure and dont have any other choice…or in men with osteoporosis since forteo only anabolic i can use in men…though now may be able to use for longer than 2 years .

Thanks, good info.

Only reason why i thought about prolia, is the ease of 6 month IM injections (I could just order it and do it in my IM clinic). I have a patient with T=-3.5, absolutely refusing PO bisphosphonates. Usually an Endorcin consult? We don't have good access to endocrin either.

 

[rokshana]

Thanks, good info.

Only reason why i thought about prolia, is the ease of 6 month IM injections (I could just order it and do it in my IM clinic). I have a patient with T=-3.5, absolutely refusing PO bisphosphonates. Usually an Endorcin consult? We don't have good access to endocrin either.

Where is that t score? Femoral neck? Lumbar spine? Are they similar? Has she had a fragility fracture? High risk for fracture? Steroid use, family history, RA, smoker?
I would consider building that up first then transition to something else later.

if you have endo or rheum access, then would consider referral to them.

 

[DrMetal]

Where is that t score? Femoral neck? Lumbar spine? Are they similar? Has she had a fragility fracture? High risk for fracture? Steroid use, family history, RA, smoker?
I would consider building that up first then transition to something else later.

if you have endo or rheum access, then would consider referral to them.

L spine. femur is -2.1. No to all other RFs. My only concern is that she's probably been that low in her spine for a long time, was lost to follow up for a while.

As far as endo/rheum referral: is that standard of care for a really bad T-score? or can/should it be managed by the PCM? Im asking, b/c i'm in a crappy gov't system that doesn't have great access to either subspecialty.

 

[rokshana]

L spine. femur is -2.1. No to all other RFs. My only concern is that she's probably been that low in her spine for a long time, was lost to follow up for a while.

As far as endo/rheum referral: is that standard of care for a really bad T-score? or can/should it be managed by the PCM? Im asking, b/c i'm in a crappy gov't system that doesn't have great access to either subspecialty.

Standard? The current guidelines say antiresorptives are first line, so utilizing either Reclast or prolia would be appropriate with close monitorinage plays a role as well… a crappy t score in a younger person has less risk of fracture than an older person with the same t score… you hear of a lot of 80 breaking a hip… not so many 50 year olds…I forgot to ask how old is she?

did you calculate a FRAX score on her? You don’t really need it with a dx of osteoporosis per se, but if a really high risk, then it could guide how aggressive to start therapy.

the discussion of utilizing anabolics first and then BPs to maintain is accepted practice and will m/l be in the next set of osteoporosis guidelines.

The discrepancy of her t scores is a bit concerning… any secondary concerns? Do you have a radius t score? Any episodes of hypercalcemia? Kidney stones?

and now you see why I have 80 min appts for new consults for osteoporosis…🙂

this can be helpful…from the 2020 aace guidelines

https://pro.aace.com/pdfs/AACE_Postmenopausal_Osteoporosis_Treatment_Algorithm_Update_022020.pdf

the full guidelines if you want to read them! The algorithm is easier!

American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update

The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American Colle…

pdf.sciencedirectassets.com

 

[DrMetal]

Standard? The current guidelines say antiresorptives are first line, so utilizing either Reclast or prolia would be appropriate with close monitorinage plays a role as well… a crappy t score in a younger person has less risk of fracture than an older person with the same t score… you hear of a lot of 80 breaking a hip… not so many 50 year olds…I forgot to ask how old is she?

She's 72-yo. No, no secondary concerns that I know of. good info, thanks. I wish I had better endocrin support in my system.