4 years ago

Retrospective evaluation of serum CTX levels after denosumab discontinuation in patients with or without prior exposure to bisphosphonates

S. L. Ferrari, B. Uebelhart, R. Rizzoli



Discontinuation of denosumab (Dmab) therapy is associated with lower serum CTX levels in osteoporotic patients previously exposed to bisphosphonates compared to those who were not.


Discontinuation of Dmab therapy is followed by a transient increase of bone turnover markers (BTMs) above pretreatment values, together with accelerated bone loss, and potentially an increased risk of multiple vertebral fractures. Since a substantial proportion of patients discontinuing Dmab have previously been exposed to bisphosphonates (BPs), we hypothesized that previous BP therapy could attenuate this increase in bone turnover because of the prolonged biological effects of BPs on bone.


In a retrospective observation, we assessed serum CTX levels between 7 and 24 months after the last Dmab injection in 37 patients (33 women and 4 men, aged 50 to 84 years). CTX levels were analyzed according to the number of Dmab injections (1 or multiple) and previous exposure to BPs.


In 8 patients who had received only 1 Dmab injection, 7 out of 8 were previously on BPs and none of them showed CTX values above the premenopausal range after Dmab discontinuation. CTX also remained in the premenopausal range in 14 out of 17 patients who discontinued Dmab after multiple (4.1 ± 1.4, range 2–7) injections but were previously exposed to BPs (mean exposure 6.9 ± 5.8 years, range 11 months–15 years; mean time interval between BP exposure and Dmab initiation 25 ± 10 months, range 0–48). In contrast, in 12 patients who discontinued Dmab after multiple (5, range 3–9) injections without prior exposure to BPs, mean CTX levels as measured on average 11.3 months (range 6–23) after the last Dmab injection were above the upper limit of premenopausal range (mean +114%, range 28–320%, p = 0.003–0.005 vs previous BPs).


The higher CTX levels occurring after Dmab discontinuation in patients who have received multiple injections may be prevented by prior exposure to BPs. This observation may be related to the persistent effects of BPs on bone that prevent the resorbing activity of newly formed osteoclasts when RANK Ligand is no more antagonized.

Publisher URL: https://link.springer.com/article/10.1007/s00198-017-4080-6

DOI: 10.1007/s00198-017-4080-6

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