Denosumab
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Multiple ipsilateral femoral stress fractures: case report A 74-year-old woman experienced three ipsilateral femoral stress fractures during treatment with denosumab for osteoporosis. The woman had a long-standing history of osteoporosis and hyperlipidaemia. In view of her active ongoing bone loss in 2013, as well as multiple risk factors for exacerbation of osteoporosis, she was prescribed denosumab 60 mg/mL every 6 months [route not stated]. Later, in 2017, 25-OH vitamin D levels were found to be low; therefore, she started receiving supplementation therapy with high-dose vitamin D 50 000IU daily alongside calcium. As a result, in 2018, 25-OH vitamin D level improved. However, she ultimately decided not to continue the high-dose vitamin D supplementation and instead, intermittently started taking a lower dose of an over-the-counter vitamin D supplement (misuse). In 2019, her vitamin D levels decreased, until which time, she had tolerated denosumab well, without any osteoporotic fractures. During follow-up in May 2019, atraumatic onset of mild, activity-related left lateral thigh pain was noted. Physical examination showed painless range of motion of the left hip and knee, and she walked with a non-antalgic gait. However, she exhibited tenderness to palpation over the left lateral thigh. Laboratory examination revealed the following: calcium 9.6 mg/dL, 25-OH vitamin D 24.6 ng/mL, ALP 60 U/L and creatinine 0.6 mg/dL. An X-ray of the left femur showed three areas of proximal femur lateral cortical hypertrophy, which raised concerns for atypical femur fractures. MRI confirmed three stress fractures with reactive marrow and periosteal soft tissue oedema in the most proximal one. Hence, the three ipsilateral femoral stress fractures were attributed to denosumab [time to reaction onset not stated]. The woman’s therapy with denosumab was discontinued, and she underwent prophylactic femur nailing. She underwent implantation of a long cephalomedullary nail of the femur without complications. Post surgery, she recovered well. During followup after healing from surgery, she was advised to initiate romosozumab to prevent a rebound effect due to denosumab discontinuation; however, she refused any further active anti-resorptive therapy. In May 2020, about a year after denosumab discontinuation, tests indicated significant loss of bone density. However, no clinical complaints were reported. Piponov HI, et al. Multiple ipsilateral femoral stress fractures in a patient taking denosumab for osteoporosis-a case report. Osteoporosis International 31: 2263-2267, No. 11, 803515894 Nov 2020. Available from: URL: http://doi.org/10.1007/s00198-020-05499-6
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Reactions 21 Nov 2020 No. 1831
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