Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab

Abstract

Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.

Keywords: bone mineral density; denosumab; fracture; osteoporosis; rebound; vertebral.

Figure 1

Flowchart of the search strategy and article selection process. Abbreviations: Dmab, denosumab; SREs, skeletal-related events; VFx, vertebral fracture.

Figure 2

Imaging of a patient with rebound-associated vertebral fractures 10 months after the last denosumab dose (4 months off treatment): (A) lateral lumbar spine X-ray at the time of acute back pain onset showing fractures at L1 and L3; (B) magnetic resonance imaging of the spine at the same time reveals additional recent fractures at L4 and L5; and (C) lateral lumbar spine X-ray 3 months later depicting deterioration of the deformities of the vertebrae (collapse of the acute, non-collapsed vertebral fractures). Fractures are indicated with white arrows.