Advice from WHSCT Rheumatology and Fracture Liaison Service 

Dr David J Armstrong, Consultant Rheumatologist WHSCT, 6th April  2020

Although treatment for osteoporosis may not seem like a priority during the coronavirus outbreak, patients will be concerned about ongoing therapy, especially denosumab (Prolia).

None of these drugs is immune suppressing, and there is no need for patient taking them to self-isolate for this reason alone.

Oral bisphosphonates

These can generally be continued without any problems

IV bisphosphonate (zoledronic acid (aclasta))

No routine iv zoledronic acid is being given on the day ward at present. Activity of the drug, which is stored in bone, continues well beyond the 12 month annual infusion, and therefore can be safely postponed.

Denosumab (Prolia) s/c

For female patients, this is administered every 6 months in primary care, after routine blood testing. The drug is not stored in bone, and bone turnover increases quite rapidly after a missed dose.

There is evidence that by 3 months after a missed dose, bone turnover can not only return to previous levels but might actually undergo a rebound increase above pre-treatment rates, with a potentially important increase in risk of fracture, especially vertebral fracture.

For these reasons, NICE, the British Society for Rheumatology and Royal Osteoporosis Society recommend that treatment with denosumab should continue if possible. This may present problems with routine blood monitoring, and I have discussed approaches with a number of other centres across the UK.

I suggest:

  1. If possible, blood testing and community administration of denosumab should continue as normal
  2. It is probably safe to postpone the injection for 4-6 weeks with no adverse consequences, but this of course presumes that we can be sure conditions for administration will be better in 4-6 weeks’ time
  3. Some experts are advising GPs to arrange for s/c administration of denosumab without blood sampling if sampling is impossible and
    1. the patient had normal adjusted calcium levels prior to the last two injections and
    2. continues to take whatever calcium and vitamin D supplement is already prescribed.
    3. I am content with this approach for stable patients, as the vast majority of our patients do have normal bloods before each injection. Some have suggested giving intramuscular vitamin D bolus as well, but I don’t see that this is necessary in most cases, it is not easily available and is not part of our standard practice. I think it would be prudent to check a bone profile in these patients once restrictions are lifted, even if this is several weeks after administration.
  4. If the patient was prone to hypocalcaemia, has a history of hyperparathyroidism or significant renal failure, or other relevant co-morbidities, the difficulty of monitoring and correcting hypocalcaemia in the current emergency outweigh the increased risk of fracture, and I would advise postponing the injection until normal blood monitoring is possible. Every effort should be made to restore the treatment as soon as blood sampling is possible

Teriparatide s/c

Patients should be encouraged to continue with daily teriparatide injections, as no regular blood monitoring is required.

 WHSCT Rheumatology and Fracture Liaison Service

Advice on any rheumatology matter is available on the helpline

WHSCT Rheumatology Helpline 02871 611173

Or specifically relating to the Fracture Liaison Service

WHSCT FLS Helpline Ext 213610

For matters specifically relating to complex osteoporosis management, it is quickest to email me directly at [email protected] rather than using the ECR referral system during the COVID epidemic, as email reply will be faster than dictating, typing and uploading my response, and e-triage is not monitored every day at present.

I will most likely still reply by a formal letter for the ECR record as well