Evenity and Bone Markers

@marymj7 I had bone markers twice trying to catch bone growth, without success. P1NP may go up the first week or two. I got tested at the end of the first month and no change in P1NP, nor was there change in the middle of the third month. I have no idea what that means but doctor thinks I missed the best time to test: probably at the end of the 2nd week.

Your P1NP is lower than mine (my baseline is in the 50's and every test, whether at 18 months with Tymlos or with Evenity, it remains there). Would love to know what you get now. Evenity may be mostly anti-resorptive at this point, according to my doc.

I have not found bone markers to be helpful but it is all in the timing.

@windyshores Thanks so much for your response. I'm afraid the dexa scan is my only way to see if it worked after going through all 12 shots. Even that is dicey, as my last Dexa one year ago was done 3 months after a moderate L4 fracture, thus throwing off the numbers. I have had unexpected dental issues crop up-so I would definitely get off Evenity if it's not working. I didn't know that the anti resorptive phase kicked in so quickly. I know once I follow with a bisphosphonate I can't have extractions, which is scary. I had to get off of Tymlos due to hypercalciuria, which I still have at baseline, to a less extent than when on Tymlos.

@marymj7 it is so hard when there are problems with so many options. I don't know exactly when Evemity becomes predominantly anti-resorptive. I was told that at first doctors thought it would be anabolic the whole year. There are a lot of unknowns. I have been told by one doc that around 4 months it becomes more anti-resoprtive. But the P1NP only goes up for a couple/few weeks.

I have 7 spinal fractures, three in lumbar spine which DEXA uses. The technician should leave out your L4 in the scoring.

I had bone markers tested prior and then every 4 months or so . Before Evenity my :
CTX 933 , then 316 , then 138 and then 39 and unfortunately that was done a week into starting Prolia .
My P1NP was 77, then 67, then 59 and now 25.
My DEXA went from T score -4.6 to a -3.3 in my spine .
The femur went from -2.1 to a -1.3 I had a 19.3% increase in the spine and a 14.0% in the femur .
I was also doing hormone replacement by biote pellets which also contributed to such wonderful results .
I am now on Prolia for a year or I may get a total of 3 injections than move on to reclast . I’m following guidelines from McCormick and my endo . I haven’t talked to McCormick just his insightful inputs on how to proceed from Evenity .

I will be getting my 10th set of Evenity injections next week. Fortunately, I haven’t had any negative side effects. My baseline markers before I began treatment were CTX 514 and P1NP of 59. The cTX shot down to 147 within 3 months and has remained around there. My P1NP, however, has been moving in the wrong direction. After two more sets of tests it is now at 29. Has anyone had a similar experience or can weigh in with any thoughts about this?

CTX and Evenity is on my research "to do list" this week. My CTX after 11 mos of Evenity is 75. I have no clue how to interpret that number. But just sharing the below remarks found on Lani Simpson's Guides on her Facebook page. I also have her book - need to check there for info as well.

Romosozumab (Evenity) has a dual effect on bone, increasing bone formation and decreasing bone resorption. While on Romosozumab (Evenity), you should see CTx decrease and P1NP increase from your baseline.
When on Romosozumab (Evenity) P1NP increases rapidly within a few days of starting treatment, peaking by around three months. The P1NP increasing indicates bone remodelling which will start to decline before you finish the course of your treatment. Meanwhile CTx decreases rapidly from baseline in the initial time, then begins increasing but remains below or near baseline at month 12.
For Romosozumab (Evenity) repeat the tests at one month and three months and then again at least before finishing treatment.
While on Romosozumab (Evenity), depending on your circumstances, some practitioners may have you continue treatment for a further period of time beyond the standard treatment period.
If you have no or minimal change in CTx or P1NP bone turnover markers when on an anabolic bone medication it might be because of issues that impact on the effectiveness of your treatment:
-poor adherence (eg not taking the anabolic bone medication at all if self-administering the injections),
-poor adherence (missing doses),
-inappropriate technique of teriparatide or abaloparatide injection,
-do you need to adjust the dose or change the type of treatment,
-a medical problem (eg recent vertebral fracture), -unidentified secondary cause of osteoporosis, or
-a real absence of response.
It’s important after completing an anabolic therapy to transition to an antiresorptive therapy to preserve bone mass. If you don’t start an antiresorptive bone medication you will start to lose any bone density gains you may have made as osteoclastic activity increases once you’re no longer on an anabolic bone medication.
Not all antiresorptive bone medications will be suitable, depending on your circumstances. You may need one of the stronger ones to manage the elevated osteoclastic activity. Test CTx before, or just after, finishing an anabolic bone medication to help in this decision making.
One of the stronger antiresorptive bone medications recommended to use after anabolic bone therapy is Zoledronate (Reclast/Aclasta). Here’s the guide I did on preparing for a Zoledronate (Reclast/Aclasta) Infusion:

@gretch19 and @255anny I have been told that the rise in P1NP is much shorter than expected with Evenity. Dr. Ben Leder's video on You Tube entitled "Combining and Sequential Approaches to Osteoporosis" has a graph that shows it rise in the first week and then rapidly go down.

I had a P1NP done at one month (and a CTX) and mine was the same as before Evenity - in the low 50's. My doctor told me I had missed the rise in P1NP because I did it at the end of the month.

One of my endos said they really don't fully understand how Evenity works and originally the expectation was that it would be a bone builder throughout, which proved not to be true- it becomes anti-resorptive which is evidenced with a lower CTX.

My doc told me that as well however the drop from pre medication is weird. I guess I should be happy that the anti resorptive aspect is working.

Hi @gretch19 P1np is known to dip below baseline level towards the last few months of evenity treatment. I think your newer p1np reading is therfore within expectations.

It seems that bone markers have to be used differently depending on each drug you are using and drugs you may have used preceding their use. In the open mic discussion at the 2024 Santa Fe conference (that
@michaellavacot so helpfully recommended to us) there is a discussion of bone markers and how they might be used for Evenity, Forteo and Tymlos. My take on it is that marker use is pretty clear for Forteo and Tymlos but for Evenity there is much less agreement as to their usefulness or how to use them. One woman mentions that while the P1NP may go down in the later months on Evenity that cortical bone formation may still be ongoing. Another mentions that P1NP goes up and down depending on how close you are to a shot. Another says that the P1NP for a person recently on bisphosphonates may take months longer to respond than a person who was not on them beforehand.
The discussion of the bone markers runs from about 12 min in to about 22min. Here's the link and you have to click on the open mic discussion in the list on the left.
https://www.ofnm.org/santa-fe-bone-symposium/?playlist=f25ab5c&video=be7cec8
My doctor had me do a P1NP at 2 months. It had gone up, nearly doubled, and he said great. He never tested again seemingly believing if you got a jump in P1NP at that point you could trust that you were responding well to Evenity. Not saying that's the best way - just reporting.

As to the BMD changes across time there is a nice chart in "Effects of 24 Months of Treatment With Romosozumab Followed by 12 Months of Denosumab or Placebo in Postmenopausal Women With Low Bone Mineral Density: A Randomized, Double-Blind, Phase 2, Parallel Group Study" found here
https://academic.oup.com/jbmr/article/33/8/1397/7605217?login=false#google_vignette .
Fig 3B is the BMD chart over time and 4A is the bone marker chart over time.
This shows the big increase in BMD is by 6 months (there was no 3 month DXA) and it slows down after that. To me I see that the gains are still good though. All the way thru 2 years.