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Osteoporosis — SCE Rheumatology MCQ

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HardMetabolic Bone DiseaseOsteoporosisSCE Rheumatology

A 70-year-old woman has received denosumab 60 mg every 6 months for osteoporosis for 4 years. She has sustained no fractures during treatment, and her latest DXA now shows T-scores in the osteopenic range. Her corrected calcium is normal, her eGFR is 58 mL/min/1.73 m², and she has no contraindication to bisphosphonates. She wishes to discontinue denosumab because she believes her osteoporosis has resolved. Which is the most appropriate management principle?

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Correct answer: E — Give sequential bisphosphonate therapy when the next denosumab dose would be due

The correct answer is E. Denosumab has no prolonged skeletal retention, so stopping or substantially delaying it permits rapid recovery of bone resorption, loss of bone mineral density and a clinically important risk of rebound-associated, often multiple, vertebral fractures. Treatment response on DXA does not remove this risk. If denosumab is discontinued, sequential antiresorptive treatment—usually an oral or intravenous bisphosphonate—should be planned around 6 months after the final injection, with subsequent monitoring tailored to fracture risk and response. A treatment-free holiday is therefore inappropriate. Denosumab is not literally lifelong, but it should not be stopped without an exit strategy. Teriparatide monotherapy does not provide the antiresorptive cover needed to suppress the post-denosumab rebound.

Reference: Tsourdi E et al. Fracture risk and management of discontinuation of denosumab therapy: a systematic review and position statement by the European Calcified Tissue Society. Journal of Clinical Endocrinology & Metabolism, 2021. https://pubmed.ncbi.nlm.nih.gov/33103722/