Men's Osteoporosis Support Group

Osteopenia fracture risk; more on Prolia

Menopause. 2010 Jun 15. [Epub ahead of print]. Determining whether women with osteopenic bone mineral density have low, moderate, or high clinical fracture risk. Langsetmo L and others. PMID: 20555289. This Canadian study involved 2,588 women who were between 50 and 90 years of age, so it is unknown if the results would apply to males. The authors note that "Most low-trauma fractures occur among women with osteopenic bone mineral density (BMD) . . ." Osteopenia would be defined as having a T-score of -1 to -2.5 and anything lower than -2.5 would be osteoporosis. The study checked for risks of low-trauma fracture other than BMD. The results showed the following factors increased fracture risk in osteopenic women: lower BMD, prior low-trauma fracture, self-reported worse general health, and height loss (particularly 44% greater risk for each 5-cm difference between current and maximal height). The authors concluded: "Including risk factors such as general health and height loss can be used to provide a highly effective assessment of fracture risk among women with osteopenic BMD."

Editor's comments. Most emphasis for osteoporosis is placed upon BMD, however, as this study notes, more fractures occur in those with osteopenia than osteoporosis. So obviously other factors, such falls, frailty, etc., are involved in fracture risk. This study finds three important ones for postmenopausal women: low BMD, prior low-trauma fracture, and loss of height. NOTE: low-trauma fracture automatically places someone in the category of osteoporosis according to World Health Organization guidelines.

In the real world most men are simply not going to know that they are osteopenic, and probably won't know they are osteoporotic. The important, and easily checked parameter that could decrease the risk of a fracture would be loss of height. I recommend that men monitor their height, perhaps with a note on a computer calendar program or paper calendar every six months or so. Something like your birthday, or the summer and winter solstice dates could be easy reminders to measure your height. Do so at the same time of the day and without shoes. If you notice a significant loss of height, (I would think that an inch or more would be important) discuss this with your care provider and consider having BMD testing done via dual-energy X-ray absorptiometry (DXA). There are several articles on the Men's Osteoporosis website regarding height loss, just do a FreeFind search with "height loss" to check them out.

J Bone Miner Res. 2010 Jun 8. [Epub ahead of print]. Effects of denosumab on bone histomorphometry: The freedom and stand studies. Reid I and others. PMID: 20533525 . The last Update was on denosumab (Prolia) and included comments about how severely bone remodeling was blocked by this osteoporosis medication. The Reid and others study used bone histomorphometry (microscopic appearance of bone) of iliac crest bone biopsies taken at 24 and/or 36 months after starting Prolia treatment to gauge various factors of bone formation, remodeling, etc. When checking microscopic bone formation researchers often use a form of tetracycline to label the bone as this antibiotic stains the bone where it is incorporated. One study found, "Double labeling in trabecular bone was observed in 94% of placebo bones, and in 19% of those treated with denosumab." They also found in the Prolia group, ". . . median eroded surface was reduced by >80% and osteoclasts were absent from >50% of biopsies. . ." Another study found, "Double labeling in trabecular bone was seen in 20% of the denosumab biopsies and in 90% of alendronate samples."

Editor's comments. These two studies cited in the Reid and others article show that Prolia blocks bone remodeling severely and much more so than alendronate (Fosamax). There are several reported instances of osteonecrosis of the jaws in the literature and multiple Updates on this topic in regard to people taking bisphosphonates for osteoporosis. The risk is apparently very minimal for those taking oral bisphosphonates, and much greater for those on I.V. forms. However the complication can be quite difficult to treat, with potentially devasting outcomes, so it is best to avoid it if possible. Osteonecrosis of the jaws has been related to the fact that the bisphosphonates block the resorption of bone by osteoclasts. This apparently doesn't allow the body to remove older, defective bone in great enough quantities, so that problems can develop, particularly after long periods on the bisphosphonates. Reid and others indicate that Prolia is even more effective than the bisphosphonates at blocking bone remodeling.

I'm unaware of any reported cases of osteonecrosis of the jaws from Prolia, but the microscopic findings as noted above would make one suspicious that those using Prolia long-term might increase their risk of osteonecrosis of the jaws. I would discuss this with your care provider if he/she suggests you take Prolia to treat your osteoporosis.

It appears that Prolia could be taken at different intervals than normally suggested, which is each six months. Perhaps every nine months, or some other longer interval. Hopefully future studies will determine if that might allow significant increase in BMD, but less severe blockage of bone remodeling, which should reduce the risk of complications while still decreasing fracture risk.

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