How would you approach osteoporosis management in a patient who fractures while on denosumab therapy?

This is a scenario that we run into at times and is very difficult with data suggesting a decline in BMD after discontinuation of denosumab as well as data from DATA-Switch trial from 2015 revealed that switching from denosumab to teriparatide resulted in progressive or transient bone loss.

I would always consider in this situation if this is due to medication failure vs. over suppression of bone turnover based on years of antiresorptive therapy vs. medication noncompliance vs. missed diagnosis of secondary causes of bone loss. In regards to the first situation, this may be someone who has started therapy and truly needs an anabolic agent. When over suppression is of concern, I have found that often individuals have had a background of year...