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Prolia – A Different Antiresorptive

February 14, 2011 @ 6:00 am
posted by Dr Ginther

Prolia (Denosumab) is the newest type of Antiresorptive medication for Osteoporosis.  Like the other Antiresorptive medications, Prolia slows down the cells that eat away bone, but in a different way.  A simple way of looking at Prolia is to think of it as “birth control” for the cells that eat away bone.  See my post about “Osteoclasts Gone Wild”.

Prolia mimics the hormone OPG which regulates the hormone RANK-Ligand which forms and activates the Osteoclast cells that eat away bone.  Good bone health is based on a balance between OPG and RANK-Ligand.  If there is too little OPG, Prolia takes over the role of OPG to bring the system back to better balance.

Prolia is given in a shot under the skin once every 6 months.  It is effective for about 6 to 9 months.  It is totally gone by 12 months unless another shot is given.  It does not accumulate in bone as Bisphosphonates do.  Therefore once it is stopped, it is gone.  It also has no ill effects on kidneys or digestive tract.

If you are over 80 or have renal disease, and have serious heartburn or reflux disease, Prolia is a good option to preserve the bone you already have.  Patients can add calcium to their bones and gain Bone Mineral Density.   Of course, for Prolia to work, you must take enough Calcium and Vitamin D.

Liver functions should be normal and Calcium and Vitamin D levels and daily intake must be maintained if you take Prolia.  It is important to have any needed dental work done before taking Prolia.  After a fracture, you should wait until healing can be seen on x-ray before taking Prolia.

Like all Antiresorptives, Prolia will suppress bone turnover.  Prolia had been used briefly in 2 patients with rare cases of Osteonecrosis of the Jaw (ONJ) and Atypical Fractures of the Femur.  There is not yet any conclusive evidence that Prolia, or any other Antiresorptive, causes these conditions.

Jay Ginther, MD

2010 / Revised Feb 2011

57 Responses to “Prolia – A Different Antiresorptive”

  1. deleted for privacy says:

    I had a prolea injection 3 months ago. I woulld like to have dental work.
    What lab work is necessary to determine if I should continue to have this procedure done.

    • Dr. Ginther says:

      You need to discuss this issue with your dentist, who can evaluate your situation.
      The good news here is that Prolia’s bone turnover suppression is fading at 6 months and TOTALLY GONE at 12 months.
      Bisphosphonate effects will gradually dwindle over several years.
      25-hydroxy Vit D, PTH and Calcium should be considered to be sure those issues are OK.
      Bone turnover markers can be helpful , but only if you had baseline studies done BEFORE you started any Antiresorptive.
      Again, talk this over carefully with your personal dental health professional.

  2. Bill says:

    Is it not true, however, that if the patient does not receive her 6 month interval injection of Prolia her BMD could be worse at the end of year one than when she began the treatment? See Prolia Package Insert 12.2

    • Dr. Ginther says:

      You have to take a medication for it to work. If a patient is losing BMD very rapidly, she could have a worse BMD a year later if she only took one Prolia shot. Still she would definitely be better off than if she had taken no medication. Prolia acts for a much shorter time than Bisphosphonates. That is good if you need dental work or bone surgery after treatment has begun. That is bad if you plan to skip doses. But the same problem applies to all medications if you skip doses – they do not work as well as they would if you take all your doses. Prolia is the best medication for some patients (such as GERD with Renal Failure). No medication is best for everyone.

      • Colleen says:

        Why is the patient better off having taken the medication than if they had never started? If the bone density decreases to a lower level because the patient has quit taking the medication, they have gained nothing and are now further in the hole. I don’t understand your logic here. Please explain

        • Dr Ginther says:

          Taking Prolia will normally increase the bone density (with proper Calcium, Vit D, Protein, etc). Taking no medication at all normally results in a loss of 1% to 2% of Bone Density each year.
          Osteoporosis is like high blood pressure or diabetes in that you must treat itfor the rest of your life or you will lose what you gained by treatment.
          Prolia does not accumulate in bone, therefore you lose the benefit if you stop taking it, and that can happen in just one year.
          Bisphosphonates accumulate in bone, so it generally takes several years to lose their benefit.
          Taking nothing at all, you have never improved your bone density and are worse off every year. Taking Prolia or another medication for only 1 or 2 years, you start going down hill, but never quite catch up to the decline you would have had with nothing.
          #### Fracture Risk reduction by meds generally runs 50-70%. This is far in excess of the BMD improvement and this generally decreases slower than the BMD after stopping meds.

  3. Debbie says:

    I have taken Prolia injections for the last year and a half. I am due Jan 9th for my next injection. Three weeks ago I had pain in a jaw tooth that had had a root canal 6 years ago. Went to dentist but since I was on prolia he referred me back to my indo dr. who immediately sent me to a oral surgeon. From all x-rays tooth cracked had to be removed. Oral surgeon had to remove some bone because of Infection there when tooth was extracted. Surgery is healing but have been told that over the next few months the bone “may” come out on the inside of my jaw by the tongue. Worst case. I am not sure if I need to take my next Prolia Injection in Jan. My bone Dr. says there is a chance that it may happen, but we have a month to heal. My questions is would missing the injection help me to not have the jaw bone troubles?

    • Dr. Ginther says:

      I am removing identifying info from your question.
      The good news is that effects of Prolia are fading by 6 months and completely out of the body by 12 months after the last shot. If you were on bisphosphonates earlier, their effects fade much more slowly.
      Either way, aggressive treatment of the broken tooth and infected socket usually succeeds.
      Standard recommendation from the national meetings is to be sure the jaw is fully healed before your next dose. This could take 3-6 months.
      Research reported at the meetings indicates that Forteo can reverse the effects of bisphosphonates within 3 months.
      A full evaluation by an osteoporosis specialist would be good.
      Jay Ginther, MD

  4. Karolyn says:

    Can you have root canal while taking Prolia?

    • Dr. Ginther says:

      I do not know the details of your situation
      These are general comments and may NOT be the right advice for you or another specific cercumstance

      Emergently, yes
      Electively I would suggest waiting until at least 3 months after your last shot
      If it is time for your next shot, et the root canal done and put off the next shot until your dentist says it is all healed

  5. Anonymous says:

    I am due for my prolia shot in febuary and should have a tooth extraction., should I stop the injection and how long should I wait before I have it
    Nicole

    • Dr Ginther says:

      I would hold off on your next Prolia until the tooth extraction is completely healed. As an orthopedic surgeon, I would estimate 6 to 12 weeks for the bone to heal. Your dentist will need to look to see if the gum is healed too.
      Once the tooth extraction is healed, Prolia should be safe to give.

  6. sharon lawrence says:

    I have to have a root canal in 2 days because there is an infection at the base of the root and it has to be cleared up as I also have Mitral Valve Prolapse . I had my 2nd Prolia shot March 20,2014 .. Is this a problem and am I in any danger with my jaw or teeth? Nervous about having root canal because of the Prolia shot..please advise…thank you

    • Dr Ginther says:

      Root Canal is not a problem
      Extraction could be a problem, but usually is not unless there are other issues such as cancer, chemotherapy, uncontrolled diabetes

  7. Dorothy says:

    I have taken my first shot of denosumab on Oct 10 and am due for the next on Nov.7. My doctor has given me the Calcium supplements and I am also on Aromasin 25mg exemostane tablets as this bone pain was due to the breast cancer cells that spread after 9 years to my hip.
    I am in need of a tooth extraction ( lower jaw premolar) and my dentist is hesitant as he feels my healing maybe affected. I have upper dentures and lower jaw dentures too with only 4 teeth in the lower jaw.Please advice how I should proceed.

    • Dr Ginther says:

      You are on Denosumab for breast cancer metastatic to bone. This is Xgeva dosing rather than Prolia dosing. This is a difficult situation with no easy answer. Your oncologist and your dentist need to talk this one over.

    • Mary Bryan says:

      Hi Dorothy I know you posted on here a few years ago
      I had breast cancer 10 years ago, I have now got Metastasis on my spine and they have recommended Denosumab, I had 3 teeth out 6 weeks ago, I am unsure of how long to wait.
      What advice was given to you, and how are you now x

      • Dr Ginther says:

        I do not know your full story and it should not be posted on an open site, therefore I have deleted your last name
        If you have mets (as my mother did) you need to talk to your oncologist about the Xgeva dosing of Denosumab, sooner the better
        Hormonal deprivatiion therapy sometimes helps
        There is very good evidence that high dose Vit D (in conjunction w other meds) to get the 25-hydroxy D level up to at least 30 ng/ml improves the success of treatment
        There is some evidence that pushing Vit D up to 70 ng/ml could help more
        I would worry about curing the cancer before worrying about my teeth
        Nutrition is a key factor
        Via con Dios

  8. Colleen says:

    Is there a continued fracture risk while taking Prolia?

    • Dr Ginther says:

      Yes. Prolia usually decreases Fracture Risk by about 70%, not 100%. But not taking anything reduces Fracture Risk by 0%. All osteoporosis meds decrease Fracture Risk. The trick is finding which is best for you.
      Of course you must take propre Calcium, Vitamin D3, etc, to get the full benefit from any osteoporosis medication.

  9. Lilly says:

    Prolia is poison!!!!!!!!!

  10. suzy says:

    Dear Dr. Ginther,
    I am a CNA and caregiver for the elderly. My good friend 90 yrs. old had a Prolia shot and the new 13 strain pneumonia shot on a Monday (recently) and had two teeth extracted and gum surgery on Tuesday. Neither doctor informed of course. Four days later she had a sever headache over her right eye that continued off and on for two-three days. Felt somewhat sick and said her head felt very “full”. I took her to the doctor and he had her go for a CT of the head. She’s still not great one week later. I happened to read the info on Prolia and it is very specific not to have dental work/extractions while on it but it does not say why. Do these symptoms sound familiar to you? Do you know how long she will have issues? Why should one NOT have dental extractions when on Prolia?
    Thanking you on advance for my friend,

    • Dr Ginther says:

      The “full head” sounds more like the Pneumonia shot.
      Tooth extractions cause tiny cracks in the jaw bone. Prolia (and all other osteoporosis medications except Forteo) work by slowing down bone turnover, which can slow bone healing. Prolia has the advantage that bone turnover returns to normal by the time for the next shot (6 months). Ideally your friend would have put off her Prolia dose until after her tooth extractions were fully healed (typically 6-8 weeks).
      Recent information from the Am Dental Assoc points out that the rare complication of tooth extractions, OsteoNecrosis of the Jaw, can usually be avoided with antiseptic mouthwashes and by carefully repairing the gums so that no bone is exposed after the extraction. This is true with patients on osteoporosis medications, as well as cancer patients, poorly controlled diabetes, etc

  11. Hessel says:

    Hello and Thank You so much for providing this info

    I last took Prolia 9 months ago (started late 2012) and just found out today I have a back molar that has a bit of an abscess (not real bad but it exists) and will need to be extracted or have periodontist see if he can save it with a bone graft eventually.

    From what I’ve read here, it appears that it should be fine to go ahead with either of these since it’s been 9 months.

    The tooth is not a great bother and I could hold off a month or two providing it doesn’t worsen .

    In your opinion, is the 9 month since the last injection plenty of time?

    Thanks again for providing info on this tedious problem. God Bless!!!

    • Dr Ginther says:

      First, without a full consultation assessing all your medical data, I am providing General Information which may not exactly fit your needs.

      Prolia is scheduled for 6 month intervals because it is no longer effective 5-6 months after the last dose. Studies have shown that a person often loses bone beginning 6 to 8 months after the last dose, and is back to ground zero 12 months after the last dose. It is usually safe to proceed with surgery on bone 5-6 months after your last Prolia.

      My advice is to proceed immediately with whatever dental procedures you need. When your dental work is entirely healed, you should able to safely resume Prolia.

      Especially if you need bone grafting, you should consider the only Anabolic, Forteo. Forteo stimulates bone formation by stimulating Osteoblasts. From my Orthopedic past, I know that Forteo often hastens and enhances bone healing. Prolia (and all other Antiresorptives) cannot do that. But you do need to follow Forteo with Prolia or other another Antiresorptive.

      Read up on Forteo before proceeding and talk that possibility over with your bone health doc.

      Best wishes for a speedy and successful recovery.

      Jay Ginther, MD

  12. Jean ford says:

    I had my first prolia shot one month ago. My dentist says I need a tooth extraction. Is it safe to have the tooth extracted 6 months from now? I had the shot July 13. So is it safe to have the tooth extraction on January 13? I am not having another prolia shot until the tooth extraction and several other areas of decay are eliminated. Unfortunately my dentist missed the decay prior to my first prolia shot.

  13. Marie says:

    I have had 3 prolia shots. 6 months ago I had eye lid surgery for bags under my eyes. I still have swelling & the surgeon is surprised it is taking so long to heal. Could it be the prolia?

    • Dr Ginther says:

      That would be a very unusual reaction to Prolia
      However, if you want to switch meds, do so when the next Prolia shot would be due
      If you do not follow Prolia w another med you could lose all the benefits you have gained

  14. Diana says:

    A week ago I finished injecting Forteo after two and a half years. I’m going to begin with Prolia as soon as possible. Unfortunately, I had to have a molar extracted last week. My dentist says my gum is healing well and that it’s protecting the bone below. I took antibiotics for three days after the extraction and have been using special mouthwash three times a day ever since.
    My dentist thinks there is no problem for me to start with Prolia as early as next week. I’d like your opinion please.

  15. Pat Jones says:

    I have read many of your posts and I would like to know if Prolia causes tooth cavities. I have been on Prolia for about 18 months and have had several cavities–my dentist “accused of eating sweets. Where can I get this info for my dentist?

    • Dr Ginther says:

      We have no evidence that Prolia can cause tooth cavities, nor is there any aspect of the action of Prolia to suggest that it could
      If you do stop Prolia remember that it must be followed 6 months after your last dose with another med to avoid losing all you have gained
      My personal bout with tooth decay (not on Prolia or any other osteoporosis med at the time) is much improved after a revised brushing protocol and special high fluoride toothpaste – which must be used with some care because Very High doses of fluoride can make bones more brittle

  16. Donna says:

    I am currently taking Reclast. I’ve had it one time only on Jan. 2016. Would it cause a problem if I switch to Prolia? Should I wait for a certain period of time before switching? Thank you for your reply!

    • Dr Ginther says:

      This can be complicated
      After 3-5 doses of Reclast, most persons have accumulated enough in their bones to go on “Holiday” for several years before restarting antiresorptive therapy
      If you have only had one dose, you can switch when the next Reclast is due
      Prolia does NOT accumulate in your bones, so a “holiday” is not possible
      You must switch to another med if you ever stop Prolia

  17. Keenie says:

    I’ve only ever had 2 prolia injections 6 months apart last one being last February. If I wait 12 months would it be ok to get 5 dental implants placed in lower jaw ? Thanks

    • Dr Ginther says:

      I would tell my patients to wait 5 months after the last Prolia
      If your dentist is worried about your bone quality, you should consider switching to Forteo
      Forteo is the only medication which will build new bone
      However, you need a full bone health eval before starting Forteo
      Waiting 12 months after your last Prolia shot risks losing all you have gained from Prolia

  18. Frances spain says:

    I had Prolia shot Jan 3, 2018. Dentist wants to do 4 implants (actual 3 implants for 4 front upper teeth) along with bone graft. Preliminary work April 3, 2018 and surgery May 11, 2018. I am very nervous with time frame. Is it safe to have this done.

    • Dr Ginther says:

      I do not know your complete history, labs, etc
      However, I usually tell my patients that the ideal time for dental or orthopedic surgery is 5 months after their last Prolia shot.
      We do not have adequate evidence to say that Prolia slows bone healing or that it definitely does not
      While it is not approved by the FDA for bone healing, Forteo (teriparatide) has been found in numerous studies (including sone in dental literature) to facilitate bone healing after surgery
      I use it in persons w poor bone BEFORE surgery for 3-6 months
      Discuss your individual case w your dentist

  19. Blanche Norton says:

    is itchy skin a good reason to stop taking prolio. will the itching continue until prolio is out of system.

    • Dr Ginther says:

      I do not know your individual circumstance. Speaking generally, itchy skin is not typical of Prolia, but is associated with dozens of conditions – including dry skin from the very low humidity indoors and out during winter in Iowa.
      A moisturizing skin lotion should help.
      6 months after your last Prolia shot you need to decide whether to continue Prolia or switch to another medication.
      You cannot simply stop Prolia without losing most of what you have gained.
      If the itching started within days of the shot and lasts about 5 months before disappearing entirely, you should probably switch.
      Talk to your doc about it.

  20. Amy says:

    Thank you for this info. I do have a question. My first Prolia shot was Sept and I’m needing gum surgery scheduled for tomorrow. I’m worried about the jaw problem since I have periodontal problems. So is this a safe time to do It? When should I get the next shot? Is there a cure for the jaw prob if someone gets that?

    • Dr Ginther says:

      (Back from 10 days with the grandkids)
      The ideal time for bone surgery, including jaw, while on Prolia, is 5 months after your last shot. As long as there is no actual bone work or tooth extraction, other times should be safe too.
      Always use antibiotic mouthwash after extractions or surgery on the jaw bone, until everything is healed.
      Prolia can be given again as soon as your dentist declares that the bone is fully healed.
      Other meds such as Fosamax, Alendronate, Actonel, Risedronate, Boniva, Ibandronate, should be stopped a month before surgery and held until “all clear” from your dentist.
      Evista, Forteo, Tymlos need not be held.

      There is a medication that will speed healing of OsteoNecrosis of the Jaw (ONJ) (which is very very rare unless after tooth extraction or surgery directly on bone).
      Forteo is cited in the dental literature as preventing and healing ONJ.

  21. Patti Schifrin says:

    I had my second Prolia injection on February 7,2018. I would like to schedule hip replacement surgery in about 6 weeks. Is that a problem with the Prolia injection? I am 72 years old.

    • Dr Ginther says:

      Surgery 5 months after Prolia is ideal
      In theory surgery sooner than that could be a problem, but we have no evidence that it actually is from looking at patients who have fractures after their Prolia shots (about 1/3 tripped in the parking lot after their shot)
      Since there has not been a specific randomized, prospective study, we cannot say for sure

      • Deborah says:

        Finished two years of Forteo about a month ago. Had root canal two weeks ago which was retreated today due to some lingering pain. How long to wait before starting IV Reclast for osteoporosis. Have severe osteoporosis. Have to take IV form dye to GERD.

        • Dr Ginther says:

          Generally a patient should follow up Forteo with an antiresorptive as soon as feasible, however, I advise patients wait until their dental issues are resolved before infusing Reclast. The dentist will know when there is little chance of a pending extraction.

  22. Joannie says:

    How long after prolia injection until I can have a tooth extracted and how long should I wait until my next prolia injection

    • Dr Ginther says:

      Emergent tooth extraction is probably safe at any time, but waiting 5 months after the last shot should be ideal.
      Generally, as soon the dentist declares an extraction healed, the next Prolia shot can be given

  23. HAV says:

    Hello

    I am on Prolia for 4.5 years which in-between I stopped prolia for a year.

    The last Prolia injection was a year ago –

    Can I go through Dental extraction and Dental implant at the same time? Or maybe only Dental extraction – Or should I wait longer?

    Thank you

    • Dr Ginther says:

      Generally patients who have had Prolia need to get their next injection by 7.5 to 8 months after the previous one to avoid a rebound in bone resorption which can erase any gains by 12 months.
      Increased vertebral fractures have been observed in patients beginning 7.5 to 8 months after the last Prolia shot who have not followed up with something other than Prolia at about 7 months after their last shot.
      The oral surgeon is best qualified to know whether in a specific case an implant can be done at the same time as an extraction.
      Generally oral surgeons recommend waiting until the extraction has healed before placing an implant.

  24. JENNIFER YOUNG says:

    Hello,
    I have had root canal therapy a week ago and today, however the Dentist is not sure if I will have further trouble and need an extraction of this tooth.
    (I have been on Prolia for nearly 6 months)
    I am due to have my next Prolia injection next Monday 15th April 2019.
    Should I wait to have the second Prolia injection next Monday? f so, how long?
    To see if the tooth calms down or I have to have an extraction.

    • Dr Ginther says:

      Uncertainty about the need for a tooth extraction is a problem
      Ideally. a tooth extraction can be done 4-6 months after Prolia at no additional risk
      We do not have firm evidence that Prolia is a problem close to a tooth extraction as long as you do aggressive routing care such as antibiotic rinses until the socket is healed.

      We do have firm evidence that delaying Prolia more than 7.5-8 months after the last injection gives an increased risk of vertebral fractures

  25. Tamzen Frignoca says:

    I have a cavity under my large cosmetic whatever it’s called. I am due for a root canal and I am nervous. Had a prolia shot late this past december.

    • Dr Ginther says:

      If a root canal is all you need, that can be done at any time. Prolia will not be a problem. In theory Prolia could delay healing after an extraction, but with ten years of experience we have not found evidence that Prolia delays bone healing.
      However, if you find that you actually need an extraction, the ideal time is 4 to 5 months after your last Prolia shot, which would be late April through early June. Do not delay more than 8 months after your last Prolia shot for your next one if at all possible. There is evidence that delaying your next shot more than 8 months can increase your chance of vertebral fracture.

    • Dr Ginther says:

      If all you need is a root canal, you can do that at any time. Theoretically Prolia can slow healing after an extraction although we have not seen that in ten years of follow-up.
      The ideal time for an extraction would be 4-5 months after your last shot, just to be safe. That would be late April through early June.
      Do not delay your next shot beyond 8 months after your last one if possible. We do have evidence that starting 8 months after the last shot some individuals are at increased risk of vertebral fracture.


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