Switching from Prolia (Denosumab) Therapy

Introduction to Switching Scenarios

The American College of Rheumatology recommends switching from Prolia to another osteoporosis medication class if a new osteoporotic fracture occurs ≥12 months after initiating Prolia therapy, with alternative options including PTH/PTHrP, oral or IV bisphosphonates, or romosozumab depending on fracture risk level 1, 2
For adults ≥40 years discontinuing glucocorticoid therapy who continue to be at high fracture risk, the American College of Rheumatology recommends continuing current osteoporosis therapy or switching to another medication class 1

Switch from Prolia if significant BMD loss occurs (≥10% per year) after 1-2 years of treatment, indicating inadequate therapeutic response requiring alternative therapy 1, 2
For glucocorticoid-induced osteoporosis, switching from denosumab to PTH/PTHrP may lead to transient bone losses in hip and spine and is not recommended; however, PTH/PTHrP followed by denosumab leads to continued BMD increases 1

Denosumab is preferred over bisphosphonates in patients with renal disease (GFR <35 mL/min) 3, 4
For adults with solid organ transplants, GFR ≥35 mL/min, and no evidence of chronic kidney disease-mineral and bone disorder, treatment decisions should be based on individual patient factors 6, 7

Bisphosphonates should be started 6-7 months after the last Prolia dose to prevent rebound vertebral fractures 1
Unlike bisphosphonates and raloxifene, denosumab requires transition to anti-resorptive therapy 1
Ensure calcium and vitamin D supplementation is adequate before and during any transition, and correct hypocalcemia before starting any alternative therapy 8