Year: 2025
Type: article
Abstract: Disclosure: H.L. Hofflich: None. L. VanWinkle: None. T. Wolinsky: None. A. Dhulipalli: None. E. Smitaman: None. Background: While the literature suggests that bisphosphonate therapy can slow avascular necrosis (AVN) and prevent collapse, there is evidence that bisphosphonates can be an etiology of AVN in sites other than the jaw. Clinical Case: Our patient is a 79-year-old female who was originally seen in the UC San Diego Health osteoporosis clinic at age 76 in 2022. Her DXA (2021) showed a T-score of -2.4 at the right femur, -2.5 at the left femur, -1.9 at the lumbar spine. The patient has no personal or family history of fractures. Her mother had a history of osteoporosis. She had no other risk factors for osteoporosis. At the February 2022 visit, patient was placed on oral alendronate 70 mg once weekly and was discharged to her PCP for monitoring. In April of 2024, patient returned to our clinic after having an MRI for three months of left shoulder pain. MRI findings: A large area of osteonecrosis/avascular necrosis in the humeral metadiaphysis and epiphysis extending to the superior humeral head articular surface. Patient was known to have Sjogren’s syndrome with +ANA and +SSA with a history of chronic dry mouth/dry eyes. In discussion with rheumatology, they did not feel that Sjogren’s was causative of AVN given her lack of systemic symptoms. Following an extensive workup, our patient was found to have no cause for her AVN other than the current use of oral bisphosphonates. Bisphosphonate therapy was discontinued and oral teriparatide was initiated. Discussion: Bisphosphonates are known to inhibit osteoclast-mediated bone resorption, leading to increased bone density. However, these agents can also disrupt normal bone remodeling, potentially leading to a reduced blood supply to bone tissue resulting in osteonecrosis. Avascular necrosis of the jaw is the most reported location, but cases of humeral head involvement are also recognized. While glucocorticoid use, alcohol consumption, and trauma are well-established risk factors for AVN, the incidence of bisphosphonate therapy causing AVN in areas other than the jaw remains rare, with limited case reports in the literature. In our patient, no other risk factors for AVN were identified. Discontinuation of bisphosphonates followed by the initiation of teriparatide, has shown effectiveness in patients with bisphosphonate-associated osteonecrosis. Conclusion: This case illustrates a rare but important complication of bisphosphonate therapy. Early recognition and discontinuation of bisphosphonates, followed by appropriate treatment such as teriparatide improves outcomes in affected patients. Further research is needed to better understand the mechanisms of bisphosphonates as the etiology of AVN and to identify patients at greatest risk for this complication. Reference: 1. Nordström P, et al. Bone-Specific Drugs and Osteonecrosis of Sites Other Than the Jaw: A Nationwide Cohort Study. JBMR. 2020 Sep 35(9):1703-1710 Presentation: Saturday, July 12, 2025
Source: Journal of the Endocrine Society
Authors: Heather Leigh Hofflich, Lindsay VanWinkle, Tamar Wolinsky, Anita Dhulipalli, Edward (Eddie) Smitaman
Language: English
Topic: Bone and Joint Diseases
Subfield: Orthopedics and Sports Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,255
OpenAlex ID: W7093309577
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