Osteonecrosis of the jaw and atypical femur fractures in patients treated with denosumab

Alexandra Papaioannou, MD, MSc, is a professor of medicine in the Divisions of Geriatric Medicine & Rheumatology at McMaster University and the lead investigator for the Long-term Care Ontario Osteoporosis Strategy. She has expertise in clinical practices that involve osteoporosis and frailty in older adults.

How would you assess the risk of osteonecrosis of the jaw (ONJ) and atypical femur fractures during the treatment with denosumab as compared with bisphosphonates?

Alexandra Papaioannou, MD, MSc: With both of these drugs, the atypical fractures in 75% of cases have a warning sign in the year prior to the fracture. They have a tooth-like ache in their thighs. And it’s really important to identify if the patients have these symptoms and x-ray both femurs.

In terms of ONJ, for both these groups it’s the same: look at their risk factors. Are they doing dental care? Are they seeing their dentist regularly? Are they at a higher risk because of immunosuppressives or other diseases, like Sjögren syndrome? Did they improve their dental care? We’re trying to modify some of their drugs if possible, such as glucocorticoids.

In terms of ONJ and atypicals, we don’t seem to see that increased risk for denosumab that seems to be increasing with bisphosphonates. It seems to be the same risk over the 10 years people are on treatment. So, whether you’re doing an annual bone mineral density (BMD) testing or every 2 years, as some societies are saying, it is still worthwhile to meet with the patient and review their oral care. Are they having any symptoms that could be associated with atypicals? Definitely individuals of Asian extraction are at a higher risk for atypical fractures, so you may want to be seeing them and reassess their treatment plan at 3 years, especially if they’re on a bisphosphonate.