Update on denosumab in the management of postmenopausal osteoporosis: patient preference and adherence

Nocebo-associated treatment discontinuation with subcutaneous anti-osteoporotic drugs. A systematic review and meta-analysis of placebo-arm dropouts in randomized-controlled trials

OBJECTIVE

Nocebo is a concept of therapeutics referring to unpleasant symptoms attributed by a patient to a drug, due to negative anticipation. Patients receiving oral anti-osteoporotic drugs in randomized controlled trials (RCT) can experience adverse events leading to dropout, implying that nocebo contributes to treatment discontinuation for these drugs. In this study we aim to investigate the nocebo effect of subcutaneous anti-osteoporotic drugs with a higher compliance rate than orally administered drugs.

STUDY DESIGN

We searched MEDLINE, EMBASE, SCOPUS, and Cochrane databases for double-blind trials investigating subcutaneous anti-osteoporotic drugs for osteoporosis (namely, denosumab, teriparatide, abaloparatide and romosozumab) published up to May 2023.

MAIN OUTCOME MEASURE

Dropouts due to reported adverse events in the placebo arms ("nocebo dropouts").

RESULTS

Data from 17 trials were extracted. Among 10,529 placebo-treated patients the pooled nocebo-dropout percentage was 3 % for denosumab (average: 0.03; 95 % CI: 0.01-0.05), 1 % for romosozumab (average: 0.01; 95 % CI: 0.00-0.03) and 6 % for teriparatide and abaloparatide (average: 0.06; 95 % CI: 0.05-0.07). Nocebo-dropouts were significantly higher in men than women (6 % vs. 3 %, respectively, p = 0.012), in older (mean age >68 years) than in younger patients (5 % vs. 1 %, respectively, p = 0.017) and in those with more severe osteoporosis (based on the percentage of participants with prior fragility-related fractures in the study cohort) compared with patients with no prior fracture history (4 % vs. 1 %, respectively, p = 0.046).

CONCLUSION

Nocebo responses may contribute to treatment discontinuation with subcutaneous anti-osteoporotic drugs in clinical practice. Higher nocebo-related dropout rates in the higher-risk RCT population (older patients, males, those with prior fractures) show that nocebo mechanisms have the potential to hinder therapeutic efforts to specific populations who would benefit most. Prospero registration number CRD42020212843.

A retrospective analysis of nonresponse to denosumab after hip fractures

Denosumab is an effective antiresorptive drug commonly prescribed for the treatment of osteoporosis. However, some patients do not respond well to denosumab treatment. The aim of this study was to evaluate the factors underlying treatment nonresponses to denosumab in elderly patients following hip fracture. This retrospective study included 130 patients treated with denosumab after osteoporotic hip fracture between March 2017 and March 2020. The patients were categorized as denosumab nonresponders if they had a T-score <-3 that persisted between dual-energy X-ray absorptiometry scans, a >3% decrease in bone mineral density (BMD), or an incident fracture on denosumab therapy. We examined the baseline characteristics associated with blunted BMD responses and compared the groups following denosumab treatment for 12 months. Of 130 patients with baseline data, 105 patients (80.8%) were considered responders. No difference in baseline vitamin D, calcium, BMI, age, gender, prior fracture history, or bisphosphonate use was observed between responders and nonresponders. A longer interval between denosumab injections was associated with suboptimal BMD response at both spine and total hip (p<0.001 and p=0.04, respectively). The overall L-BMD and H-BMD were significantly increased compared with pretreatment levels after denosumab treatment (5.7% and 2.5%, respectively). This study revealed that nonresponse was not strongly associated with certain baseline variables and it appears that the reponders and nonresponders were reasonably comparable in this study population. The results of our study highlight the importance of timely denosumab administration when using this drug for osteoporosis management. Physicians should keep these results in mind in clinical practice so that they can improve utilization of 6-month denosumab.

Denosumab versus zoledronic acid in elderly patients after hip fracture

BACKGROUND

Two injectable anti-osteoporosis medications, denosumab and zoledronic acid, have been widely used to treat patients with severe osteoporosis. The purpose of this study was to evaluate the real-world effectiveness and adherence of denosumab compared to zoledronic acid in geriatric patients after a hip fracture.

METHODS

A total of 282 patients treated with osteoporotic hip fracture between March 2014 and Aug 2022 were retrospectively reviewed. The patients were asked to select the anti-osteoporosis medication after surgery. Treatment persistence was monitored by follow-up visit to the outpatient clinic at postoperative 2 years.

RESULTS

Of 282 individuals with baseline data, 162 patients took subcutaneous denosumab and 120 patients took intravenous zoledronic acid. At postoperative 2 years, the change in bone mineral density (BMD) from baseline was greater in the denosumab group compared with the zoledronic acid group (p < 0.001). The rate of persistence to denosumab was significantly higher than that for 12-months zoledronic acid (p = 0.01). Serious adverse events were similar in the two groups.

CONCLUSIONS

Our study revealed the effectiveness and patients' persistence for two commonly used anti-osteoporosis agents after hip fracture. In this frail, elderly population, half-yearly denosumab was superior to yearly zoledronic acid in BMD and demonstrated significant higher persistence rate, indicating a potential therapeutic advantage that warrants further validation.

Efficacy and safety of the biosimilar denosumab candidate (Arylia) compared to the reference product (Prolia®) in postmenopausal osteoporosis: a phase III, randomized, two-armed, double-blind, parallel, active-controlled, and noninferiority clinical trial

Background/objective

Osteoporosis is a global health concern with an increasing prevalence worldwide. Denosumab is an antiresoptive agent that has been demonstrated to be effective and safe in osteoporotic patients. This study aimed to compare the efficacy and safety of the biosimilar denosumab candidate (Arylia) to the originator product (Prolia®) in postmenopausal osteoporotic patients.

Methods

In this randomized, double-blind, active-controlled, noninferiority trial, postmenopausal osteoporotic patients received 60 mg of subcutaneous Arylia or Prolia® at months 0, 6, and 12 and were followed up for 18 months. The primary endpoint was the noninferiority of the biosimilar product to the reference product in the percentage change of bone mineral density (BMD) in 18 months at the lumbar spine (L₁-L₄), total hip, and femoral neck. The secondary endpoints were safety assessment, the incidence of new vertebral fractures, and the trend of bone turnover markers (BTMs).

Results

A total of 190 patients were randomized to receive either biosimilar (n = 95) or reference (n = 95) denosumab. In the per-protocol (PP) analysis, the lower limits of the 95% two-sided confidence intervals of the difference between Arylia and Prolia® in increasing BMD were greater than the predetermined noninferiority margin of − 1.78 at the lumbar spine, total hip, and femoral neck sites (mean differences [95% CIs] of 0.39 [− 1.34 to 2.11], 0.04 [− 1.61 to 1.69], and 0.41 [− 1.58 to 2.40], respectively). The two products were also comparable in terms of safety, new vertebral fractures, and trend of BTMs.

Conclusion

The efficacy of the biosimilar denosumab was shown to be noninferior to that of the reference denosumab, with a comparable safety profile at 18 months.

Trial registration

ClinicalTrials.gov, NCT03293108; Registration date: 2017–09-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02840-8.

Does the VDR gene polymorphism influence the efficacy of denosumab therapy in postmenopausal osteoporosis?

INTRODUCTION

One of the challenges of personalized medicine is a departure from traditional pharmacology toward individualized, genotype-based therapies. Postmenopausal osteoporosis is a prevalent condition requiring intensive treatment, whose effects are measurable only after a long time, and the goal is bone fracture prevention. This study aimed to determine the influence of VDR gene variation on anti-osteoporotic one-year treatment with denosumab in 63 Polish women with postmenopausal osteoporosis.

MATERIALS AND METHODS

The correlation between bone mineral density (BMD) of the lumbar vertebral column (L1-L4) and femoral neck, and genotype distributions for the ApaI, BsmI, FokI, and TaqI variants of the VDR gene was analyzed. Bone fractures during denosumab therapy were also investigated.

RESULTS

In the case of the Bsml polymorphism, female patients with BB and Bb genotypes had statistically significantly higher values of BMD and T-score/Z-score indicators, which persisted after a year of denosumab treatment. Our results indicated that the Bsml polymorphism contributes to better bone status, and, consequently, to more efficient biological therapy. The study did not reveal significant differences between changes (delta) in BMD and genotypes for the analyzed VDR gene loci. In the entire study group, one bone fracture was observed in one patient throughout the yearlong period of denosumab therapy.

CONCLUSIONS

BB and Bb genotypes of the Bsml polymorphism of the VDR gene determine higher DXA parameter values both before and after one-year denosumab therapy in postmenopausal women with osteoporosis.

Medical treatment of osteoporosis

Osteoporosis is a common chronic condition that markedly increases the risk of fractures. Osteoporotic-related fractures increase morbidity and mortality and impair quality of life. Therefore, a correct approach for fracture prevention seems mandatory. Lifestyle changes should be recommended to all patients, including weight reduction if patients are obese/overweight, increasing physical activity and avoiding alcohol consumption and smoking. Additionally, calcium and vitamin D3 should be prescribed until the vitamin D deficit is resolved. Osteoporosis treatment options mainly include antiresorptives (i.e. estrogens, selective estrogen receptor modulators, bisphosphonates, denosumab) and anabolic agents (i.e. teriparatide, abaloparatide, romosozumab). Although presenting differences in efficacy and side effects, they have all been shown to increase bone mineral density (BMD) and to reduce osteoporotic-related fractures. Monotherapy with antiresorptive agents, particularly oral bisphosphonates, should be considered routinely as the first option for treatment of postmenopausal women. However, in the case of side effects, therapeutic failure or the need for long-term use, anabolic agents may be considered. In high-risk patients, anabolic agents may be considered as an initial therapeutic option. The combination of antiresorptive and anabolic agents may be useful to increase BMD compared with monotherapy, but more information is warranted to determine the effects on fracture risk.

Patients' first-year adherence to different anti-osteoporotic therapy after hip fractures

BACKGROUND

Osteoporosis medication treatment is recommended after geriatric fractures. However, the percentage of patients receiving anti-osteoporotic treatment after a hip fracture is extremely low.

OBJECTIVES

The aim of this study was to evaluate the adherence to different anti-osteoporotic medications in elderly patients following hip fracture.

METHODS

This retrospective study included 520 patients treated with osteoporotic hip fracture between March 2014 and June 2019. The patients were asked to choose the medication for osteoporosis treatment at discharge. Adherence was monitored by follow-up visits to the outpatient clinic at 1 year following surgery.

RESULTS

Of 520 patients with baseline data, osteoporosis medications were prescribed to 250 (48.1%) patients. Of these patients, 110 (44.0%) took subcutaneous denosumab, 69 (27.6%) took oral selective estrogen receptor modulator, 55 (21.0%) took intravenous bisphosphonate. At 12 months, we followed up 178 (71.2%) patients. Of those prescribed a bone protection medication, only 85 patients (34.0%) reported still taking their medication 1 year later. The rate of adherence to 6-month subcutaneous denosumab injection was significantly higher than that for quarterly intravenous bisphosphonates (p = 0.024) or daily oral tablets (p = 0.028).

CONCLUSIONS

This study revealed patients' adherence for osteoporosis treatments after hip fracture. 6-month subcutaneous denosumab injection was preferred over 3-month intravenous injection or daily oral tablets in this elderly population and exhibited significant lower discontinuation rates. However, because of the limited power of the study, further research is required to identify the reasons behind non-adherence and to improve adherence to anti-osteoporosis medications.

Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the pharmacological management of osteoporosis in postmenopausal women.

CONCLUSIONS

Evidence from clinical trials and insights from clinical experience with pharmacologic therapies for osteoporosis were critically evaluated in formulating this guideline for the management of postmenopausal osteoporosis. Patient preferences, data on adherence and persistence, and risks and benefits from the patient and provider perspectives were also considered in writing committee deliberations. A consensus by the Writing Committee members was achieved for four management principles: (i) The risk of future fractures in postmenopausal women should be determined using country-specific assessment tools to guide decision-making. (ii) Patient preferences should be incorporated into treatment planning. (iii) Nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk. (iv) Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk with acceptable risk-benefit and safety profiles.

Denosumab or oral bisphosphonates in primary osteoporosis: a "real-life" study

PURPOSE

To compare the response to denosumab (DMAb) therapy with that of oral bisphosphonate (BISPH) treatment in postmenopausal women with primary osteoporosis (PO).

METHODS

In this retrospective study, we compared data of 75 PO female patients treated for 24 months with DMab (DMAb Group, age 72.6 ± 8.9 years) with those of 75 PO patients treated with oral bisphosphonates (BISPH Group), matched for age, body mass index, femoral bone mineral density (BMD), prevalent fragility fractures and familiar history of hip fracture. In all subjects at baseline and after 24 months we assessed the calcium-phosphorous metabolism parameters, BMD at lumbar spine (LS-BMD) and femoral neck (FN-BMD) by dual X-ray absorptiometry and the morphometric vertebral fractures by radiograph. The patients were considered inadequate responders in the presence of ≥ 2 incident fragility fractures and/or a decrease in BMD greater than the least significant change (LS 2.8%, FN 5.9%).

RESULTS

After 24 months, the DMab Group showed a greater ALP decrease (- 22.8 ± 18.2%), a higher LS-BMD and FN-BMD increase (6.6 ± 6.9 and 4.4 ± 8.2%, respectively) and a lower number of patients with an incident fracture (8%) and with an inadequate response (6.7%) than BISPH Group (- 14.9 ± 15.3, 2.5 ± 4.3, 1.9 ± 4.5, 21.3 and 22.7%, respectively, p < 0.05 for all comparisons). The inadequate response was 4.5-fold more likely in BISPH Group than in DMab one (p = 0.027), regardless of possible confounders.

CONCLUSIONS

In postmenopausal PO females, denosumab was more effective than oral bisphosphonates in increasing BMD and reducing bone turnover and the number of inadequate responder patients.

Clinical efficacy of PVP and PKP in the treatment of OVCFs after bilateral resection of ovarian cancer

The clinical efficacy of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer was investigated. Eighty-six patients with osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer admitted to the Second People's Hospital of Hefei from September, 2015 to August, 2016 were selected and randomly divided into control group (n=43) and observation group (n=43). The control group was treated with PVP, while the observation group received PKP. The operation time, fluoroscopy times, bone cement volume and leakage rate of patients in the two groups were recorded; the postoperative pain of patients was compared using Short-form McGill Pain Questionnaire; the changes in height of injured vertebra and Cobb angle of patients in two groups were compared; the efficacy of patients in the two groups was compared in accordance with Oswestry dysfunction index (ODI) and Japanese Orthopedic Association (JOA) low back pain scoring; and the quality of life was compared. The fluoroscopy times and bone cement leakage were significantly less in observation group than those in control group (P<0.05). After operation, the scores of ODI, MPQ and JOA in the two groups were significantly improved (P<0.05). The postoperative height of injured vertebra and the Cobb angle of patients in two groups were significantly different than those before the operation (P<0.05). The quality of life of patients in the observation group was higher than that in the control group one year after operation (P<0.05). In conclusion, PKP and PVP are effective in the treatment of osteoporotic vertebral compression fractures after bilateral resection of ovarian cancer; however, PKP is more conducive to lumbar stability and maintenance of intervertebral height thus greatly correcting the kyphosis, which is beneficial to improving the quality of life of patients.

Denosumab - a new medication in the treatment of postmenopausal osteoporosis

Osteoporosis is a chronic, systemic skeletal disorder characterised by decreased bone density. It leads to an increased risk of bone fractures - one of the major causes of disability in modern societies. Bisphosphonates are the most commonly used medications in the treatment of postmenopausal osteoporosis. Denosumab, a new approach to fracture prevention, is a fully human monoclonal antibody that targets nuclear factor-κB ligand (RANKL), an important cytokine regulating formation and function of osteoclasts. Generally, denosumab is not used as initial therapy; however, in some cases it should be considered. It concerns patients at high risk of fracture, such as older patients who have difficulty with the dosing requirements of oral bisphosphonates or who have markedly impaired renal function. Denosumab can be also considered in patients who present intolerance or unresponsiveness to other therapies. Clinical studies have shown that denosumab is highly effective in increasing bone mineral density (BMD) in postmenopausal women regardless of the site analysed, as well as reducing the risk of bone fractures. The risk of developing antiresorptive, agent-induced osteonecrosis of the jaw related to denosumab therapy is low.

Prompt clinical and biochemical response to denosumab in a young adult patient with craniofacial fibrous dysplasia

BACKGROUND

We report on the clinical and biochemical outcomes in a 20-year-old male suffering from active craniofacial monostotic fibrous dysplasia (MFD) of the left mandible treated with the RANK-L inhibitor, denosumab, following unsatisfactory responses to prior long-term bisphosphonates therapy.

RESULTS

The patient had been treated over 9 years with pamidronate (cumulative dose of 810 mg) with incomplete control of pain. Following initiation of denosumab 60 mg subcutaneously, bone pain and bone turnover markers (osteocalcin, total and bone alkaline phosphatase and carboxy-terminal cross-linking telopeptide of type I collagen) were monitored over a 27 months period. Few hours after the first administration, the patient demonstrated a complete pain disappearance and after 4 weeks bone turnover markers fell within the normal range. Three months after denosumab initiation the patient reported a pain reactivation that required a second administration, which again led to the pain disappearance. Subsequently, denosumab was administered according to the pain reappearance and the injection was always followed by complete pain relief. However, a gradual shortening of the pain-free interval between administrations was observed, ranging from 90 to 75 days. All bone turnover markers stayed in the lower half of the normal range, even at the moment of pain reappearance, suggesting that the effect of denosumab on pain depends on mechanisms other than bone resorption suppression. No side effects were reported by the patient during the follow-up.

CONCLUSION

Denosumab appears to be effective in reducing bone turnover and bone pain in adult patients with active MFD.

MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review

In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.