Online reviews have treatment stalled

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 (every six months) until we get some positive feedback. She had breast cancer five years ago (lump removed) and seems to be in pretty good health, considering. She has asthma and COPD, and is a little overweight. She doesn’t want to deal with the horrible side effects, as some of them don’t seem to go away (reading the reviews). We know that a lot of what you read on the internet is rubbish, so we are asking for different opinions, including yours. DEAR READER >> 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 (a rare but dangerous complication). Atypical fractures of the femur from dense but brittle bone (usually occurring after more than five years of treatment) 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 among those prescribed Prolia. 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 longterm safety records. Prolia, in my opinion, is best reserved for people who cannot use other agents.

Contact Dr. Roach at ToYourGoodHealth@med. cornell.edu.