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Anastasilakis AD, Makras P, Paccou J, Bisbinas I, Polyzos SA, Papapoulos SE. Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab. J Clin Med 2023; 12:5874. [PMID: 37762815 PMCID: PMC10532339 DOI: 10.3390/jcm12185874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.
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Affiliation(s)
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
| | - Julien Paccou
- Department of Rheumatology, University of Lille, 59000 Lille, France;
| | - Ilias Bisbinas
- First Department of Orthopaedics, 424 Military General Hospital, 564 29 Thessaloniki, Greece;
| | - Stergios A. Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Socrates E. Papapoulos
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Center for Bone Quality, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Tutaworn T, Nieves JW, Wang Z, Levin JE, Yoo JE, Lane JM. Bone loss after denosumab discontinuation is prevented by alendronate and zoledronic acid but not risedronate: a retrospective study. Osteoporos Int 2023; 34:573-584. [PMID: 36602607 PMCID: PMC9813893 DOI: 10.1007/s00198-022-06648-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/13/2022] [Indexed: 01/06/2023]
Abstract
A retrospective study of 121 patients who stopped denosumab (Dmab) then received no treatment (NT), risedronate (RIS), alendronate (ALN), or zoledronic acid (ZOL). Bone density (spine and hip) during and after Dmab discontinuation was measured. Treatment with ALN or ZOL, not NT and RIS, mitigated BMD loss after Dmab discontinuation. INTRODUCTION Denosumab (Dmab) discontinuation is associated with bone loss and multiple vertebral fractures. The purpose was to compare bone mineral density (BMD) change in patients following Dmab discontinuation with no subsequent treatment (NT) and three bisphosphonate (BP) treatments: risedronate (RIS), alendronate (ALN), and zoledronic acid (ZOL). METHODS In a review of 121 patients aged 71.2 ± 8.1 years, discontinuing Dmab (mean 5.4 doses), 33 received NT and 88 received BP (22 RIS; 34 ALN; 32 ZOL). BMD change after 1 year was compared between groups at the lumbar spine (LS), femoral neck (FN), and total hip (TH). Risk factors for bone loss after Dmab discontinuation were compared between groups and incidence of vertebral fractures was determined. RESULTS Following Dmab discontinuation, LS mean change (g/cm2; 95% CI) was for NT: - 0.041 (- 0.062 to - 0.021); RIS: - 0.035 (- 0.052 to - 0.017); ALN: - 0.005 (- 0.020 to 0.009); and ZOL: - 0.009 (- 0.025 to 0.008). Differences in LS were found between NT and ALN (p = 0.015), and NT and ZOL (p=0.037), but not between NT and RIS. The only significant difference in TH was found between NT and ZOL (p 0.034) with no group differences in FN. BMD gains during Dmab treatment were associated with BMD loss after Dmab discontinuation. In a subset, discontinuation after Dmab treatment (> 5 doses) followed by ALN (n = 22) and ZOL (n = 11) showed no difference in BMD. Five of 7 vertebral fractures occurred after Dmab discontinuation in NT. CONCLUSION Subsequent treatment with ALN or ZOL but not NT and RIS mitigates BMD loss after Dmab discontinuation.
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Affiliation(s)
- Teerapat Tutaworn
- Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedic Surgery, Phramongkutkloa Hospital, Ratchathewi, Bangkok, Thailand
| | - Jeri W Nieves
- Hospital for Special Surgery, New York, NY, USA
- Department of Epidemiology, Columbia University, New York, NY, USA
| | - Zhaorui Wang
- Weill Cornell Medical College, New York, NY, USA
| | | | - Jae E Yoo
- Hospital for Special Surgery, New York, NY, USA
| | - Joseph M Lane
- Hospital for Special Surgery, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA.
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Inojosa AC, Mendes L, Bandeira L, Bandeira F. The Role of Bisphosphonates Prior to Denosumab Treatment on Rebound Fractures: A Mini Review. J Bone Metab 2022; 29:217-223. [PMID: 36529864 PMCID: PMC9760774 DOI: 10.11005/jbm.2022.29.4.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/01/2022] [Indexed: 12/14/2022] Open
Abstract
Denosumab is a potent anti-resorptive medication used to treat patients at high risk for osteoporosis; however, its beneficial effects on the skeletal system are quickly reversed after discontinuation. In contrast, bisphosphonates (BPs) are anti-resorptive agents with residual effects on the bone matrix; thus, these are capable of preserving bone mass for a long time. Therefore, subsequent anti-resorptive treatment with BPs is mandatory to prevent rebound fractures. Furthermore, BP administration before denosumab treatment appears to be a reasonable strategy for reducing hyperactivation of bone remodeling. In this review, we summarize the effects of BP administration before denosumab treatment in preventing rebound fractures after denosumab discontinuation.
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Affiliation(s)
- Arthur Costa Inojosa
- Division of Endocrinology, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife,
Brazil
| | - Laís Mendes
- Division of Endocrinology, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife,
Brazil
| | | | - Francisco Bandeira
- Division of Endocrinology and Diabetes, FBandeira Endocrine Institute, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife,
Brazil
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Anastasilakis AD, Polyzos SA, Makras P, Trovas G, Yavropoulou MP, Tournis S. Efficacy of Antiosteoporotic Medications in Patients With Rebound-Associated Fractures After Denosumab Discontinuation. J Clin Densitom 2021; 24:591-596. [PMID: 33541775 DOI: 10.1016/j.jocd.2021.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
Denosumab discontinuation results in rapid bone loss and increased risk of multiple rebound-associated vertebral fractures (RAVFs). The optimal treatment for patients who have sustained such fractures is currently unknown. We aimed to investigate the bone mineral density (BMD) changes achieved with various regimens in postmenopausal women who had sustained RAVFs after denosumab discontinuation in everyday clinical practice. In this multicenter, retrospective observational study, 39 Greek postmenopausal women from six regional bone centers throughout Greece with RAVFs after denosumab discontinuation were included. We collected BMD and fracture data before and 1 year after treatment with denosumab (n = 20), teriparatide (n = 8), zoledronate (n = 8) or teriparatide/denosumab combination (n = 3). Both lumbar spine (LS)-- and femoral neck (FN)-BMD were preserved with all regimens used. With the exception of zoledronate, a trend towards increase was observed with all regimens in LS-BMD. Three patients sustained additional fractures despite treatment reinstitution (2 with zoledronate and 1 with teriparatide). Among patients with RAVFs following denosumab discontinuation both antiresorptive (zoledronate and denosumab) and anabolic (teriparatide) treatment as well as the combination of denosumab with teriparatide seem to be effective in terms of BMD response.
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Affiliation(s)
| | - Stergios A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - Georgios Trovas
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Maria P Yavropoulou
- Endocrinology Unit, 1st Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
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Denosumab Discontinuation and the Rebound Phenomenon: A Narrative Review. J Clin Med 2021; 10:jcm10010152. [PMID: 33406802 PMCID: PMC7796169 DOI: 10.3390/jcm10010152] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 01/26/2023] Open
Abstract
Denosumab is a potent antiresorptive agent that substantially increases bone mineral density and reduces fracture rates at all skeletal sites for as long as it is administered. However, its favorable skeletal effects reverse quickly upon its discontinuation, because of a vast increase of osteoclast number and activity, which leads to a subsequent profound increase of bone turnover above pre-treatment values, a phenomenon commonly described as “rebound phenomenon”. More importantly, most patients experience rapid, profound bone loss due to this burst of bone resorption that may lead in a minority of these patients to occurrence of fractures, especially multiple vertebral fractures. Therefore, subsequent antiresorptive treatment is mandatory, although the optimal regimen is yet to be clarified. In the present review, we outline what is currently known regarding the negative effects of denosumab discontinuation on different aspects of bone status, the factors that may affect them, and strategies to prevent them.
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Kashii M, Ebina K, Kitaguchi K, Yoshikawa H. Romosozumab was not effective in preventing multiple spontaneous clinical vertebral fractures after denosumab discontinuation: A case report. Bone Rep 2020; 13:100288. [PMID: 32548215 PMCID: PMC7284126 DOI: 10.1016/j.bonr.2020.100288] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/27/2020] [Accepted: 06/02/2020] [Indexed: 02/04/2023] Open
Abstract
Discontinuation of denosumab is associated with the increase of bone turnover markers to above-baseline levels (so-called rebound in bone turnover) and rapid bone loss. Several studies have reported vertebral fractures (VFs), particularly multiple spontaneous clinical VFs (MSCVFs), occurring after discontinuation of denosumab. There is currently no recommendation for the management of VFs including MSCVFs. Presently, romosozumab is the strongest anti-osteoporotic agent that inhibits sclerostin and rapidly increases bone mass, but it is uncertain that romosozumab is an effective treatment choice to treat VFs occurring after discontinuation of denosumab. Herein we reported a novel case of a 60-year-old woman who was treated with romosozumab after discontinuation of denosumab and subsequently suffered MSCVFs under romosozumab treatment. She had a history of two osteoporotic VFs (T6 and T8) and received five doses of 60 mg denosumab every 6 months following the osteoporosis diagnosis. As per the patient's convenience, the sixth denosumab injection was postponed. To improve the persistent low bone mass in the lumbar spine (T-score −3.8), 210 mg romosozumab was administered monthly after 9 months following the last denosumab injection. At the first romosozumab injection, she had no clinical symptoms such as low back pain, but her bone formation and resorption marker levels elevated compared with those treated with denosumab. After three doses of romosozumab, spontaneous severe low back pain occurred, and time-course radiographs revealed five new VFs (T12, L2, L3, L4, and L5). Romosozumab administration had no suppressive effect on bone resorption during the rebound in bone turnover after discontinuation of denosumab. This case suggests that romosozumab is not effective in preventing VFs or MSCVFs after denosumab discontinuation.
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Affiliation(s)
- Masafumi Kashii
- Department of Orthopedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kosuke Ebina
- Department of Musculoskeletal Regenerative Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kazuma Kitaguchi
- Department of Orthopedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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