MSK-24 · Osteoporosis Part 2

Osteoporosis Part 2. Topics: Treatment and Fracture Management. Part of the Musculoskeletal series of the Reflex PM&R Board Review podcast. Audio corrections: (1) In the audio: The typical holiday is 2 to 3 years for oral users and 3 to 6 years for IV users. Why longer for the IV? Simply because the IV dose saturates the skeleton more heavily and takes longer to clear. — Correct: The holiday length is not route-specific. The long-term bisphosphonate task force gives one range, about 2 to 3 years, whichever agent came before. What the route changes is the reassessment point that opens the question: 5 years for oral therapy and 3 years for intravenous therapy. A patient still at high fracture risk at that point is a candidate for continued treatment out to 10 years oral or 6 years intravenous rather than a holiday at all. (2) In the audio: First, as you mentioned, it is perfectly safe for patients with severe chronic kidney disease, even those on dialysis, because antibodies are broken down into amino acids. — Correct: Denosumab is not renally cleared, so it stays on-label once creatinine clearance falls below the bisphosphonate floor, dialysis included, but it is not "perfectly safe" there. Since January 2024 it carries an FDA boxed warning for severe hypocalcemia in advanced chronic kidney disease, added after dialysis patients started on denosumab showed severe hypocalcemia far more often than those started on an oral bisphosphonate. Correct hypocalcemia and CKD mineral and bone disorder and assure calcium and active vitamin D before the first dose, then check calcium frequently, particularly 2 to 10 weeks after each injection. (3) In the audio: The cement hardens in minutes, stabilizes the microfractures, and provides almost immediate dramatic pain relief. — Correct: Pain after vertebroplasty usually eases over days rather than immediately, and the evidence is contested. Blinded trials of vertebroplasty against a sham procedure found no significant benefit for pain, function or quality of life, kyphoplasty has no blinded trial of its own, and board sources therefore call vertebral augmentation controversial. (4) In the audio: After about five years of oral therapy, or three to five years of IV zoledronic acid, you stop the drug. — Correct: The intravenous reassessment point is 3 years, not 3 to 5. The long-term bisphosphonate task force reassesses fracture risk after 5 years of oral therapy or 3 years of intravenous therapy; the 3-to-5-year phrasing that appears in the underlying literature is route-agnostic and describes the reassessment window across both routes, not an intravenous-specific figure (PMID 26350171). Reassessment is also not automatically a stop: a patient still at high risk at that point (older age, low hip T-score, high fracture-risk score, prior major fracture, or a fracture sustained on therapy) is a candidate for continued therapy out to 10 years oral or 6 years intravenous rather than a holiday at all. The separate correction on holiday LENGTH is the other entry for this episode. The written chapter is correct. Full correction register: https://www.reflexpmr.com/errata. The full companion chapter and a linked board-style Q-bank set for this topic are at https://www.reflexpmr.com/read/MSK-24.