Romosozumab (Anti-Sclerostin — Severe Osteoporosis)

How it works

By inhibiting sclerostin it both increases bone formation and decreases bone resorption, producing a dual anabolic and antiresorptive effect that rapidly raises bone mineral density.

Prescribing in practice

• It is contraindicated in patients with a history of myocardial infarction or stroke because trials showed an excess of cardiovascular events, so cardiovascular risk must be assessed before starting.
• Correct hypocalcaemia and ensure adequate calcium and vitamin D before and during treatment.
• Rare osteonecrosis of the jaw and atypical femoral fracture can occur, and a subsequent antiresorptive agent is needed afterwards to maintain bone-density gains.

Monitoring

Monitor calcium levels and fracture/cardiovascular risk, and review for jaw symptoms and new thigh or groin pain during the treatment course.

Counselling the patient

• Tell us about any history of heart attack or stroke before starting.
• Maintain adequate calcium and vitamin D intake.
• Report new jaw, thigh or groin pain, and dental problems.

Evidence & guidelines

Efficacy in reducing vertebral fractures is supported by randomised trials, with NICE recommending it for severe osteoporosis after careful cardiovascular risk assessment.