How do you transition to an anabolic agent in a patient who develops an atypical fracture while on denosumab?

It is not usual to suffer an atypical fracture of the femur from denosumab, however, they do occur. It is useful to start an anabolic agent, either abaloparatide or teriparatide for both augment fracture healing and to treat the osteoporosis. Both abaloparatide and teriparatide stimulate bone formation and also the production of RANKL that activates bone remodeling. Since denosumab is an antibody to RANKL, there may be less osteoclast maturation and osteoclast activity. It should be safe to institute an anabolic agent, however, it would be prudent to wait at least 8 weeks after the denosumab injection and to be sure the patient is receiving recommended calcium and vitamin D supplementation. After the fracture heals and when the anabolic agent is discontinued, the patient will need to be treated with some type of antiresorptive agent to maintain bone mass.