The relationship of denosumab pharmacology and osteonecrosis of the jaws

Denosumab is a new bone antiresorptive agent that has received approval by the Food and Drug Administration for use in patients with osteoporosis and metastatic cancer to the bones. Like the bisphosponates that are used as antiresorptive medications, denosumab has been associated with osteonecrosis of the jaws (ONJ). However, because the pharmacodynamics and pharmacokinetics of denosumab differ from that of the bisphosphonates, ONJ related to denosumab may resolve more rapidly with a drug holiday than bisphosphonate-related osteonecrosis of the jaws (BRONJ). This paper describes the management of a patient who developed ONJ while receiving denosumab, reviews the incidence of ONJ associated with denosumab, and compares the pharmacology of denosumab and the bisphosphonates. Because the effects of denosumab on bone turnover are more rapidly reversible than the effects of the bisphosphonates, ONJ related to denosumab may resolve more quickly with a drug holiday than BRONJ.