Zoledronic acid maintains BMD gains after teriparatide, denosumab combination therapy
Click Here to Manage Email Alerts
Following short-term therapy with teriparatide plus denosumab with a single dose of zoledronic acid may prevent bone loss associated with denosumab cessation among postmenopausal women, according to a study published in the Journal of Bone and Mineral Research.
“Discontinuation of denosumab results in high-turnover bone loss and increased fracture risk,” Sabashini Ramchand, MD, a research fellow in the endocrine unit at Massachusetts General Hospital, told Healio. “Limited data is available regarding the optimal follow-on drug, dose and schedule after denosumab discontinuation. In our study, a single dose of zoledronic acid given 24 to 35 weeks after the last dose of denosumab was effective at maintaining the large and rapid gains in spine and hip bone mineral density for at least 12 months following discontinuation of combination therapy with denosumab and teriparatide for 15 months.”
Ramchand and colleagues conducted a single-arm, open-label extension of the DATA-HD study, in which a cohort of postmenopausal women were randomly assigned to 20 g or 40 g teriparatide (Forteo, Eli Lilly; Bonsity, Alvogen) daily for 9 months combined with 60 mg denosumab (Prolia, Amgen) at 3 and 9 months. The cohort was followed for 15 months in the original study. All 60 women who completed DATA-HD were invited to enroll in the extension, in which they received a single 5 mg dose of zoledronic acid by IV injection 24 to 35 weeks after their last denosumab dose. All participants were postmenopausal women aged at least 45 years with a high risk for fractures. Areal BMD of the posterior-anterior lumbar spine, total hip, femoral neck and the distal one-third of the radial shaft were analyzed by DXA 27 and 42 months after the DATA-HD baseline. Adverse events, including fractures, were documented during the extension period.
Fifty-three women participated in the DATA-HD extension study (mean age, 65.7 years; 98% white), of which 49% had a previous clinical fracture. At the lumbar spine, participants had a mean BMD gain of 13.6% during the original study. That gain was maintained at 27 months, but decreased about 3% at 42 months, lowering the mean lumbar spine gain from baseline to 42 months to 10.1%. The study cohort had a 5.1% mean gain in total hip BMD and 5.6% mean increase in femoral neck BMD from baseline to 15 months, with both gains maintained during the extension study. BMD gains at the distal one-third of the radial shaft were maintained at 27 months but decreased to values similar to baseline at 42 months. There was no difference in BMD changes between women who received 20 g teriparatide during DATA-HD and those receiving 40 g.
Most participants maintained or gained BMD from month 15 to month 27, 92% at the lumbar spine, 93% at the total hip and 75% at the femoral neck. From month 15 to month 42, the percentage of participants gaining or maintaining BMD was 50% at the lumbar spine, 87% at the total hip and 78% at the femoral neck.
There were four participants with clinical fractures during the extension portion of the study, with two sustaining fractures from significant trauma and the other two sustaining minimal trauma fractures. No vertebral fractures were reported during the study.
“Short-term combination therapy with denosumab and teriparatide followed by zoledronic acid may be a particularly effective strategy in the long-term management of patients at high risk of fragility fracture,” Ramchand said. “Further work is needed to define the ideal treatment strategy after long-term denosumab therapy, including the optimal scheduling of follow-on treatment after denosumab discontinuation. Additionally, larger and/or longer trials are needed to assess fracture outcomes with follow-on therapy after denosumab discontinuation.”
For more information:
Sabashini Ramchand, MD, can be reached at sramchand@mgh.harvard.edu.
Collapse
Click Here to Manage Email Alerts