PEARL: If the BMD is worsening (outside the margin of the least significant change), this should prompt a reevaluation of denosumab therapy

Common causes to consider:

• Medication nonadherence – denosumab requires administration by health care professional but during COVID exceptions were made for self administration.

• There is an unaddressed/unrecognized/untreated secondary cause of osteoporosis.
  • Obtain labs: CBC, CMP, alkaline phosphatase, phosphorus, magnesium, parathyroid hormone, thyroid function test,  25-hydroxy vitamin D, 24-hour urine calcium and creatinine (off calcium supplements, diuretics)
  • Perform a medication review and address culprit medications if possible

• Consider evaluating for secondary causes of osteoporosis as guided by labs, history and physical exam:
  • For example, anemia and hyperproteinemia suggests multiple myeloma, a low vitamin D may suggest a malabsorption state caused by celiac disease
  • Consider additional evaluation for secondary osteoporosis

• Consider alternative antiresorptive
  • The patient may have a poor response to denosumab therapy and needs a stronger agent
  • Teriparatide or Abaloparatide, or Romosozumab

Consider endocrinology consultation if further guidance or diagnostic certainty is needed