Denosumab has no tail. Its effect stops when the dose is late, and rebound bone turnover begins within months of a missed injection, so the clinically useful question is when the next dose was due rather than when the last one happened. A patient who last had an injection eight months ago is four months overdue and in the window where vertebral fractures cluster.
This matters in fracture clinic because that is often where it is discovered. A woman presenting with sudden back pain who has been on denosumab and stopped - for a move, a supply gap, a hospital admission, a dental procedure that was never rescheduled - is a vertebral fracture until imaged otherwise, and the drug history explains the presentation.
So make the interval explicit. Write the due date, not the given date, in the letter; ask about it at every review; and treat a lapsed patient as needing a plan today rather than a reminder next time. The plan is not restarting and hoping - it is deciding, with whoever prescribes their osteoporosis treatment, what follows.
- Record the date the next denosumab dose is due, not the date the last was given
- Ask any patient with new back pain on or recently off denosumab about their last injection
- Image the spine before attributing new back pain to mechanical causes in this group
- Treat a lapse as urgent - the rebound window is months, not years
- Name in the letter who is responsible for the next injection; supply gaps are the usual cause
Why it matters
A drug with no tail turns an administrative lapse into a fracture risk, and the lapse is invisible if you only record what was given.
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