Denosumab
- Denosumab (Prolia®) is an amber list drug indicated for post-menopausal women at increased risk of fracture. Further details can be found in the Shared Care Guideline.
- Withdrawal of denosumab is associated with a rapid fall in bone density and the potential for rebound vertebral fractures. Patients should not stop denosumab without specialist review.
- Given the difficulties in stopping denosumab treatment NOGG advise that particularly careful consideration is needed before starting denosumab for osteoporosis in younger postmenopausal women, and men. Note –use in post-menopausal women is the only licensed indication currently approved for use in NI.
Hormone Replacement Therapy (HRT)
- HRT should be considered for women who have experienced a premature menopause to reduce their risk of osteoporotic fractures and for relief of menopause symptoms.
- HRT should not be considered first-line therapy for the long-term prevention of osteoporosis in women over 50 years of age. It is an option where other therapies are contraindicated, cannot be tolerated, or if there is a lack of response. For most women the benefits of HRT outweigh the small risks up to the age of 60 years and women will gain bone protection if they are taking HRT for symptom relief.
Raloxifene
- Raloxifene is an alternative option for patients for the secondary prevention of osteoporotic fractures in postmenopausal women in line with NICE TA161. It is not recommended for primary prevention.
- Raloxifene has not been shown to prevent non-vertebral fractures.
Red list treatments for specialist use only
- Romosozumab
- Teriparatide
Anabolic drug treatments (romosozumb or teriparatide) are sometimes considered as first-line treatment options (before bisphosphonates) in postmenopausal women at very high fracture risk, particularly in those with vertebral fractures, where NICE criteria are met.
Strontium
When other antiresorptive and anabolic treatments are contraindicated or not tolerated, strontium can be used to treat postmenopausal osteoporosis and men with severe osteoporosis, provided the risk-benefit in relation to cardiovascular and thromboembolic events is considered. Initiation by a specialist who is an expert in osteoporosis management is advised.