Bad reviews cause doubt in treatment

Dear Dr. Roach: My wife’s doctor wants her to start Prolia shots for bone density, but the reviews I have been reading are extremely negative. She cancelled her appointment to start the shots until we get some positive feedback. — J.A.

Online reviews may be a good way of learning about buying some things, but I would caution that somebody who does fine with a medicine is not apt to write a review of it, so you are likely to see a very biased sample. Denosumab (Prolia) is an antibody, given by injection, that prevents the formation of osteoclasts, the cells that break down bones. By reducing bone breakdown, bones are built up, and fracture rate (especially of the vertebral bones) was reduced at three years in a clinical trial, from 7.2 percent in the placebo group to 2.3 percent in the Prolia group. However, there are some reasons to be concerned. One is that many people (the drug has mostly been used in women) noted pain of the muscles and bones, sometimes severe. Like other osteoporosis drugs that work this way (the bisphosphonates), Prolia can cause lower calcium levels, and it may oversuppress bone remodeling, leading to osteonecrosis of the jaw. Atypical fractures of the femur from dense but brittle bone also are possible. When Prolia is discontinued, the bone rapidly loses strength, and rebound fractures may occur, so a different treatment should probably be started soon. Prolia also interferes with the immune system, with some evidence that there may be increased infection and tumor rates. If that’s the case, the number seems low. I do not use Prolia as a first-line treatment for osteoporosis. There are other drugs (like the bisphosphonates, such as alendronate and risedronate) with better long-term safety records. Prolia, in my opinion, is best reserved for people who cannot use other agents.