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Postmenopausal osteoporosis treated with denosumab — SCE Rheumatology MCQ

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ModeratePostmenopausalPostmenopausal osteoporosis treated with denosumabSCE Rheumatology

A 74-year-old woman with postmenopausal osteoporosis and a previous low-trauma vertebral fracture has received denosumab 60 mg every 6 months because an oesophageal stricture precludes oral bisphosphonates. Her seventh injection was missed because of an administrative error. She presents 8 months after her sixth injection. She has had no new fracture, and recent DXA shows improvement from osteoporotic values to T-scores of −1.9 at the lumbar spine and −2.0 at the total hip. Albumin-adjusted calcium, 25-hydroxyvitamin D and renal function are satisfactory. She has no active infection, planned invasive dental treatment or adverse effect requiring denosumab withdrawal. Which is the most appropriate management of her osteoporosis treatment?

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Correct answer: C — Administer denosumab now, then schedule subsequent injections every 6 months from today's injection

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

A missed denosumab injection should be administered as soon as possible; subsequent injections are then scheduled every 6 months from the date on which the delayed injection is given. Her improved T-scores do not justify an unprotected treatment interruption. Unlike bisphosphonates, denosumab has a rapidly reversible antiresorptive effect, and delayed administration is associated with loss of treatment effect and increased vertebral fracture risk. A would prolong the interruption without benefit and incorrectly attempts to preserve the previous calendar. C treats attainment of osteopenic T-scores as an indication for a drug holiday, an approach that is inappropriate for denosumab, particularly after a previous vertebral fracture. D is a plausible strategy when denosumab is being deliberately discontinued, because an alternative antiresorptive is then required; however, there is no clinical reason to stop denosumab in this case, and the licensed missed-dose instruction is to administer it promptly. E confuses monitoring strategies used when planning sequential therapy after denosumab withdrawal with management of an inadvertently missed dose. A serum CTX result is not required before resuming treatment.

Reference: Prolia 60 mg solution for injection in pre-filled syringe — Patient Information Leaflet (21 July 2026) — https://www.medicines.org.uk/emc/product/568/pil Prolia 60 mg solution for injection in pre-filled syringe — Summary of Product Characteristics (23 July 2026) — https://www.medicines.org.uk/emc/product/568/smpc Delayed Denosumab Injections and Fracture Risk Among Patients With Osteoporosis: A Population-Based Cohort Study (2020) — https://pubmed.ncbi.nlm.nih.gov/32716706/