Anti-resorptive therapy with denosumab in elderly and senile patients with osteoporosis: a narrative review and clinical recommendations

Abstract

Senile osteoporosis represents one of the most pressing challenges in modern geriatric medicine, characterized by high prevalence, delayed diagnosis, and severe complications such as low-energy fractures, which are associated with disability, loss of independence, and significantly increased mortality. The pathogenetic mechanisms underlying fracture development in the elderly are multifactorial, encompassing not only bone loss but also sarcopenia, increased fall risk, and comorbid conditions, necessitating a comprehensive therapeutic approach. Denosumab, a fully human monoclonal antibody against RANKL, occupies a pivotal position in the management of senile osteoporosis due to its potent anti-resorptive activity, convenient subcutaneous administration once every 6 months, and favourable safety profile, as confirmed in 10-year clinical trials. This narrative review presents current evidence on the epidemiology of senile osteoporosis, the pathogenesis of its complications, and the place of denosumab in treatment algorithms according to current clinical guidelines. Particular emphasis is placed on practical aspects of denosumab use in geriatric patients: preparation with calcium and vitamin D supplementation, management of patients with chronic kidney disease, post-fracture treatment strategy, utilization in long-term care facilities, as well as potential pleiotropic effects, including impact on fall risk, type 2 diabetes mellitus, osteoarthritis, cardiovascular system, and muscle mass. The review is based on data derived from randomized controlled trials, meta-analyses, retrospective cohort studies, and real-world clinical practice. Evidence indicates that, while demonstrating comparable efficacy to bisphosphonates, denosumab exhibits a more favourable safety profile, which is of particular importance in frail elderly patients. Special consideration is given to the recent introduction of the denosumab biosimilar – Forsedeno® – onto the Russian pharmaceutical market, which substantially enhances the accessibility of long-term anti-resorptive therapy. The feasibility of prolonged, including lifelong, denosumab therapy in older patients is substantiated, taking into account the persistently elevated risk of recurrent fractures and the favourable long-term safety profile of the drug.