The Doctors Reply after Prolia AFF and now recommends Forteo

Would you consider combination therapy? with or without bone markers?

@smg22 I have read and heard that Forteo is ineffective after Prolia. McCormick's book "Great Bones" andDr. Ben Leder's videos on You Tube (including Sequencing and Combination Approaches to Osteoporosis" make this very clear. One person on this forum posted a study on Evenity after Prolia that showed it was effective in combating rebound though effectiveness was somewhat reduced (not as much as with Forteo!). Maybe the person who posted that can post it again.

It is true that both Prolia and bisphosphonates are anti-resorptive with similar risks. For that matter, the last months of Evenity are too. But bisphosphonates are most often used to combat rebound.

Prolia puts people in a bind unfortunately. I would get a second opinion if an MD suggests Forteo after Prolia or at least show your doctor the book or videos (I know that's awkward) or have a discussion.

@windyshores - thank you and my (new) doctor's reasoning was that due to the sudden & intense jaw pain that I experienced 1-week after my last Prolia shot back in June 2024, he was reluctant to put me on a Bisphosphonate due to potential risks for further issues (osteonecrosis); as they too can cause it. I did ask him for Reclast (I was on that prior to Prolia), and he said it's the strongest of the Bisphosphonates and said no to it. If my insurance denies Forteo, then he will put me on Fosamax.

@gently I mainly rely on Dr/ Ben Leder's video on Combination and Sequential Approaches to Osteoporosis as well as McCormick's "Great Bones."

Leder says combining Forteo and Prolia has dramatic effects. Forteo first (for 9 months as I remember) with Prolia coming on and intersecting. His video says that combining Forteo with a bisphosphonate does not improve over either alone.

All the sources I have seen say that Forteo and Tymlos are ineffective after Prolia and should not be considered.

Leder's videos have a lot of graphs and charts that make all this visually clear. I am relying on memory so check them out. He is a leading MD and researcher at Mass. General in Boston. He is also on OsteoBoston on You Tube.

These positions conflict with those in the study posted by @gently. Here is the conclusion in that:
"It is clearly time to re-evaluate the potential benefits of combination therapy, with a careful attention to effects on both spine and hip. In patients who have previously received bisphosphonate agents, there is no question that different results are achieved at the hip and perhaps other sites rich in cortical bone with combination vs individual therapy. The current study by Walker et al. adds to the growing literature that suggests that even in patients who have not been on bisphosphonate treatment previously, a superior hip BMD response might also be achieved with combination therapy (in this case, teriparatide plus risedronate). These differences might be clinically meaningful, particularly for patients at highest risk for hip fractures, including those who have had a recent hip fracture, multiple prevalent fractures, or extremely low hip BMD."

This clearly challenges the oft cited idea that bisphosphonates reduce effectiveness of anabolics.

@sbax75 Your difficulty brings up a problem I hadn't considered. How to deal with the difficulties of dealing with the dangers of stopping Prolia and the damage (atypical femur fractures) caused by mainly antiresorptive osteo meds at the same time. What I'm going to say below is rather speculative and I have not been in your shoes. That said, I'll speculate.

You cannot just stop Prolia without losing a lot of bone, that's for sure. And some people don't just lose a lot of bone but they have multiple fractures.
So,
On the one hand the safest known way to get off of Prolia is with Reclast.
But on the other hand if you have already been on Prolia 6 years and have had an AFF then you need to get some remodeling going in your bones. Some modest clean up and some bone building both. But not out of control cleanup like can happen with the stoppage of Prolia.

As @windyshores has just commented Forteo and Tymlos are not considered safe follow ups to Prolia. Too much bone clean up may happen and at least initially you may lose bone using either of those. That basically leaves Evenity which can hopefully get your bone building and remodeling going without the clean up side being too activated. After Evenity gives you a period of remodeling you could hopefully safely try Reclast or another bisphosphonate to preserve bone. Perhaps alternating bone builders and bisphosphonates down the road to get periods of bone building and remodeling and periods of mainly preserving the bone you have but not having such long periods of suppressed remodeling as six years of Prolia gives you.

There's one study where Evenity was given both before and after Prolia in one arm of the study. It appeared to work fine with no new safety concerns on the year of Evenity following Prolia. Those following Prolia with Evenity were able to gain more in the spine and break even in the hips. Not the same benefits as giving Evenity as the first osteoporosis med though still benefit.

But this study does not directly apply to your situation. The length of time on Prolia before the second Evenity round was only one year. Very different than six years. This is an important study with a wealth of information but one year of Prolia is just very different than six years. Perhaps there are other studies that cover a longer time period on Prolia or at least doctors who have used Evenity after years of Prolia successfully. If you have the time it could be very useful to get more information on Evenity after long term Prolia use.
Here's the paper I mentioned above: https://link.springer.com/article/10.1007/s00198-019-05146-9
I wish you the best of luck

What about stopping prolia after only 6 months (1 injection)
I've already used forteo for two years, alendronate for 5 years and just finished Evenity with good results for one year followed by one injection of Prolia. I am uncomfortable starting of prolia for the remainder of my life at 76 1/2. I am still wondering about going back on Evenity

What about stopping prolia after only 6 months (1 injection)
I've already used forteo for two years, alendronate for 5 years and just finished Evenity with good results for one year followed by one injection of Prolia. I am uncomfortable starting of prolia for the remainder of my life at 76 1/2. I am still wondering about going back on Evenity

What was your experience with Evenity, as far as side effects? Did you do anything before and after the injections to prevent possible side effects? You mentioned going back on Evenity, but I thought it was only recommended for one year? Thank you.