Prolia (denosumab) is an injectable medication used to treat osteoporosis and increase bone mass in individuals at high risk for fracture. It works by blocking a protein called RANKL, which is involved in the breakdown of bone. While effective, Prolia can have significant drug interactions and contraindications that patients and healthcare providers must carefully consider to avoid serious adverse effects. From other bone-strengthening drugs to certain cancer therapies and immune-suppressing medications, understanding what to avoid is a critical part of a safe treatment plan.
Primary Medications to Avoid with Prolia
Other Denosumab Products (Xgeva, Jubbonti, Wyost, Stoboclo)
Prolia contains denosumab as its active ingredient. There are other products, such as Xgeva, that also contain denosumab but are approved for different uses, typically at a higher dose for cancer-related bone complications. It is an absolute contraindication to take Prolia alongside any other medication containing denosumab. Taking multiple denosumab products simultaneously significantly increases the risk of severe side effects.
Bisphosphonates
Bisphosphonates are another common class of drugs for treating osteoporosis, including alendronate (Fosamax), risedronate (Actonel), and zoledronic acid (Reclast). Prolia and bisphosphonates both work to limit bone resorption. Using them together is not recommended, as it can compound the risks of certain side effects, most notably osteonecrosis of the jaw (ONJ), without providing additional therapeutic benefit. For patients who previously used a bisphosphonate, switching to Prolia should be a carefully managed process overseen by a healthcare provider.
Calcimimetics
Calcimimetics, such as cinacalcet (Sensipar) and etelcalcetide (Parsabiv), are used to treat hyperparathyroidism. These medications, along with Prolia, can lower blood calcium levels. Combining them substantially increases the risk of severe hypocalcemia, a dangerous and potentially life-threatening condition. Patients with chronic kidney disease are at an even higher risk for this interaction.
Increased Risk Medications and Special Considerations
Immunosuppressants and Corticosteroids
Prolia can weaken the immune system, increasing the risk of serious infections. Patients taking other immunosuppressant medications or corticosteroids for conditions like asthma, inflammatory bowel disease, or autoimmune diseases are at an even greater risk for infection. Examples of these drugs include prednisone, cyclosporine, and adalimumab. The concurrent use of corticosteroids also increases the risk of ONJ.
Other Cancer-Related Medications
Certain therapies used in cancer treatment, including chemotherapy agents (cyclophosphamide), angiogenesis inhibitors (bevacizumab), and mTOR inhibitors (everolimus), can increase the risk of ONJ when combined with Prolia. Patients with a history of cancer are already at higher risk for this side effect, making vigilance even more important.
Live Vaccines
Due to Prolia's immunosuppressive effects, live vaccines (e.g., measles, mumps, rubella [MMR], chickenpox, and the nasal spray flu vaccine) should be avoided. Your immune system may not be able to effectively respond to the weakened virus or bacteria in the vaccine, potentially leading to illness. Consult with your healthcare provider about scheduling non-live vaccines while on Prolia.
Table of Common Drug Interactions with Prolia
| Drug Class | Examples | Associated Risk | Management Recommendation |
|---|---|---|---|
| Other Denosumab Products | Xgeva, Jubbonti | Significantly increased risk of all Prolia side effects | Do not take together. |
| Bisphosphonates | Alendronate, Risedronate | Increased risk of hypocalcemia and ONJ | Typically avoided or managed by specialist. |
| Calcimimetics | Cinacalcet, Etelcalcetide | Severe risk of hypocalcemia | Close monitoring or alternative therapy. |
| Corticosteroids | Prednisone, Dexamethasone | Increased risk of infection and ONJ | Monitor closely for symptoms of infection or dental problems. |
| Immunosuppressants | Adalimumab, Cyclosporine | Increased risk of serious infection | Monitor closely, consider risk-benefit. |
| Live Vaccines | MMR, Nasal Flu Spray | Risk of developing illness from the vaccine | Avoid live vaccines during treatment. |
| Calcium Supplements | Various brands | Reduced absorption of certain antibiotics (e.g., ciprofloxacin) | Separate dosing time from certain antibiotics. |
Lifestyle Factors and Dental Health
Alcohol Consumption
While no direct interaction has been identified between Prolia and alcohol, excessive drinking can be detrimental to bone health and increase the risk of fractures, especially in patients already at high risk. It is best to limit or avoid alcohol during treatment to support overall bone health.
Pre-existing Hypocalcemia
Prolia can cause severe hypocalcemia (low blood calcium), and this risk is significantly higher in patients with pre-existing low calcium levels or advanced kidney disease. Your healthcare provider must correct any hypocalcemia before you start Prolia. All patients should take daily calcium and vitamin D supplements while on Prolia, as directed by their doctor, to help prevent this serious side effect.
Dental Procedures
Patients on Prolia have an increased risk of osteonecrosis of the jaw (ONJ), a condition involving jawbone decay. Before starting Prolia, a dental exam is highly recommended, especially if you have risk factors like poor oral hygiene or planned dental surgery. If an invasive dental procedure, such as a tooth extraction, is necessary while on Prolia, you must inform your dentist and consult your healthcare provider. Your provider may recommend delaying the procedure or temporarily stopping the medication.
Conclusion
Navigating medications and their interactions requires careful planning and communication with your healthcare team. It's crucial to inform your doctor and pharmacist about all other medications, supplements, and vitamins you are taking before starting Prolia. By being aware of what you should not take with Prolia, including other denosumab products, bisphosphonates, calcimimetics, and immunosuppressants, you can mitigate risks like severe hypocalcemia, infections, and ONJ. Additionally, maintaining good dental hygiene, managing calcium levels through supplementation, and avoiding live vaccines are important steps to ensure the safety and effectiveness of your Prolia treatment plan. If Prolia is discontinued, your doctor will likely transition you to another antiresorptive agent to prevent rebound fractures. For more comprehensive information, refer to the official Prolia Prescribing Information.
