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Update Evenity followed by 2 years of alendronate
So DEXA just showed that my 22.9% spine gain is now only 11% meaning I lost that much in a year. And femoral neck about the same loss. So I went backwards considerably but haven’t fractured. Have not seen doc yet (Nov 6)
Frustrated and sad. I had great results from Evenity after a year that continued after 1 year of alendronate and expected continued improvement. Nothing else has changed. I exercise regularly, resistance work, swimming and walking 4-5 miles daily. (very active) Vitamin D is 51. All labs good. Waiting on CTX. Last from May 2025 was 361.
I was hoping for a drug holiday after 2 full years of alendronate. I surprised myself as I tolerated it very well, never missed a dose! I just turned 69 and so far no one will give me HRT. I had a coronary calcium score that was zero. I was worried as my cholesterol was creeping up to 259 with an LDL of 151 but an HDL 66 so I started rosuvastatin 20 mg daily but after the coronary calcium dropped it to three times a week . Now cholesterol is 152 and LDL down to 69 maintaining HDL at 70. This is essentially the only change I made.
No fractures and vertebral fracture assessment was negative.
What do I do next? I need a long term plan. Can I do a short course of Evenity or will the alendronate blunt it. Was the alendronate not strong enough. Should I have gone right to reclast? Is it too late since I’ve already lost so much? I’m scared of Prolia. T-scores spine is now 2.3 and femoral neck is 3.0. I essentially lost BMD everywhere taking alendronate this last year! I just don’t understand. Any input most welcome 🙏
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🙂 I also have indigestions from reading that article! The coupling concept has been discussed quite a bit in the literature - I added a citation mainly to prove I’m not making this stuff up, haha. As you pointed out, coupling is a very complex process involving overlapping mechanisms- biochemical (endocrine and paracrine), biomechanical, and cellular - and it’s certainly not one-way.
The TRIO study (Three Oral Bisphosphonate Therapies in Postmenopausal Osteoporosis) demonstrated an early decrease in the bone resorption marker CTX, followed by a subsequent decrease in the bone formation marker P1NP, as shown in the attached figures (alendronate data). That lagging pattern shows, indirectly but clearly, how resorption and formation remain linked, or “coupled", even under antiresorptive therapy.
Oops, I posted a wrong (risedronate’s) graph.
Here is a correct graph for bone formation marker changes during alendronate therapy:
@mayblin Is OC Osteocalcin? Why do you prefer this graph over the one showing CTX and P1NP? What is the source of these graphs.
If these graphs are correct, I need to re-think what I thought I understood about osteroporosis.
@rjd
Yes, OC is osteocalcin. I’m posting the bone marker changes during alendronate therapy here again, side by side for easy comparison. The right side shows resorption markers CTX (orange line) and NTX, while the left side shows bone formation markers BSAP, OC, and P1NP (cobalt blue line). Click the graphs for the full legend. Source:
https://files.core.ac.uk/download/pdf/30271498.pdf
This review paper “The bone remodeling cycle” by Kenkre:
https://journals.sagepub.com/doi/10.1177/0004563218759371
is quite insightful and helped me understand bone remodeling. You might find it helpful too.
@mayblin translate this..
@mayblin
CTX is 293…… Haven’t seen endo yet but brief portal
conversations have him leaning towards another course of evenity. Appt isn’t until nov 6 and bunion surgery nov 14. Podiatrist trying to call him for guidance.
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1 Reaction@nycmusic I’ll give it a try.
Here’s how one reputable paper explains the coupling concept in bone remodeling: “Coupling refers to the cellular and molecular mechanisms that ensure the spatial and temporal linking of bone resorption by osteoclasts to the formation of bone by osteoblasts at the same remodeling site.”
The main purpose of the TRIO clinical study was to compare the efficacy and safety of three oral bisphosphonates. Bone turnover markers were measured during the study, and the results showed that resorption and formation are tightly connected. In the authors’ words “Bisphosphonates reduce bone turnover beginning with inhibition of osteoclastic resorption, which leads to a delayed but corresponding reduction in bone formation, consistent with the concept of coupling where bone formation is dependent on prior resorption activity.”
In simpler terms, during bisphosphonate’s treatment, osteoclasts slow down first, and the osteoblasts soon follow - one process leads to the other -that’s coupling in action. I think that’s the easiest way to picture it.
Thanks for the update! CTX of 293 suggests your bone turnover is still modestly active, which is actually good if an anabolic therapy is being considered.
With your upcoming bunion surgery and brief immobility, starting an anabolic soon could help protect bone and likely build more bone mass. Another course of Evenity is a reasonable option, and a PTH analog could also be considered, imo, depending on timing and preference.
@hikernurse
Thanks for sharing. Do you know if original Medicare will cover a second round of Evenity?
@gravity3
I don’t know that right now but I would think if the doc does all the right paperwork work and he’s the one to suggest. I’ve somewhat failed alendronate and quite resistant to reclast and prolia. Might need them later as I just turned 69. And will prob need reclast after evenity!! I will keep everyone posted. I’ve gained so much from all of you. I’m also putting everything together consult with Keith McCormick.
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