Every other osteoporosis drug tolerates a missed dose. Denosumab does not. Stopping it — or being late with a dose — releases a rebound in bone turnover that can produce multiple vertebral fractures within months, in patients who had none before, and the fractures often present as sudden back pain rather than as a scan finding.
So treat the six-monthly date as a hard appointment, not a target. When the drug is started, the exit plan should be agreed at the same consultation: what will follow it, and when. In practice that means a bisphosphonate to hold the gains, timed from the date the next denosumab dose would have been due, not from the date the patient happened to attend.
And flag it wherever a different clinician might stop the drug for them — before surgery, during an admission, at a dental review, or when a repeat prescription lapses. A patient who does not know that missing this injection is dangerous is the commonest route to a rebound fracture.
- Book the next denosumab dose before the patient leaves, every time
- Agree the follow-on antiresorptive at the point of starting denosumab, not at the point of stopping
- Time the sequential bisphosphonate from when the next dose would have been due
- Tell the patient explicitly that missing a dose carries fracture risk, and write it in the notes and the discharge summary
- New sudden back pain in someone who has recently stopped denosumab is a vertebral fracture until imaged
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