DIONJ

Question 1

What are the diagnostic criteria for DIONJ?

Answer 1

• History of anti-resorptive medications
• Exposed bone of the maxillofacial region for more than 8 weeks
• No Hx of H&N radiation and absence of metastatic disease

Question 2

What drug is Fosamax, when is it used, what is its relative potency, and what is the dosage?

Answer 2

Alendronate
Osteopenia, osteoporosis, metabolic bone disease
1,000
70mg/week

Question 3

Which drug causes the majority of cases of DIONJ in pts receiving oral anti-resorptive medications?
What percent?

Answer 3

Fosamax
96%
It is marketed at 2x the dosage of other oral drugs despite identical absorption, potency, 11 yr half life, and bioavailability as the others

Question 4

At what duration of oral bisphosphonate use is the pt at risk for DIONJ after an oral surgical procedure?

Answer 4

Starting at 2 yrs after steady weekly use and becomes significant at 3 yrs.

Question 5

Other than DIONJ, what other significant complication is associated with prolonged use of oral bisphosphonates?

How long are bisphosphonates shown to be useful?

Answer 5

Subtrochanteric femur fractures

Benefit does not extend beyond 3 years, and risk outweighs benefit at 5 years

Question 6

What lab value has been shown to be of benefit in predicting surgical outcomes in pts taking bisphosphonates?

What does it test?

What are the pretesting requirements?

Answer 6

Blood serum CTX

8 amino acid collagen split product released by osteoclasts which reflects bone turnover

Morning fasting draw

Question 7

What is the minimum CTX level which suggests proper healing following a surgical procedure in a pt on bisphosphonate therapy?

Answer 7

150 pg/ml

Question 8

In which situations is the CTX value not useful?

Answer 8

• Cancer pts bc of excess fibrin split products produced by malignancy which cross reacts w the test and registers higher values
• Pts on Denosumab
• Pts on methotrexate and steroid therapy as this suppresses collagen synthesis and registers lower values

Question 9

What is the protocol for determing the risk of DIONJ in a pt who cannot obtain a CTX?

Answer 9

A 9 month - 1 year drug holiday is recommended

Question 10

What are some alternative treatments to bisphosphonates for pts with osteopenia/osteoporosis

Answer 10

Calcium and Vitamin D

Raloxifene (Evista)

Recombinant human parathyroid hormone 1-34 (Forteo)