How do you approach long term management of glucocorticoid-induced osteoporosis in patients who develop osteonecrosis of the jaw on antiresorptive agent?

Osteonecrosis of the jaw is a rare complication of anti-resorptives with the exception of high doses used for cancer patients. Teriparatide (TPTD) has been anecdotally reported to assist in healing of ONJ. The patient described remains on glucocorticoids and is at very high risk for fracture, especially of the spine.

TPTD has been shown to be effective and superior to (Alendronate) ALN In patients on glucocorticoids. Since the primary pathophysiology of chronic glucocorticoids is decreased bone formation, it makes perfect sense to use an anabolic (TPTD or abaloparatide) for at least 2 years then reassess fracture risk. If fracture risk remains high and the patient remains on steroids then more than 2 years may be merited.

Use a different agent. If onj happened on a bisphosphonate go to danosumab. Risk factors should also be optimized. If dental surgery is scheduled hold the anti-resorptive.