Inclusion criteria:
Postmenopausal women aged between 45 up to 75.
Bone mineral density T score at the lumbar spine (L1-L4), femoral neck or total hip should be equal or less than -2.5 and equal or more than -4. (-4 ≤T score ≤−2.5); or patients with high risk of fracture on the basis of FRAX criteria which according to osteoporosis treatment guidelines, need medicinal treatment
Ability to comprehend and willingness to sign the Informed Consent Form for this study;
Signed informed consent with full knowledge and mental health.
Exclusion criteria:
Lack of consent for being in the trial and not complying with an 18-months follow-up.
Having hypersensitivity to denosumab or any component in the formulation (excipients include acetic acid, sorbitol, Polysorbate 20, sodium hydroxide, water for injections)
Malabsorption syndrome
History of thyroid surgery, parathyroid surgery or intestinal resection which has been caused malabsorption
Patient with CKD stage 4 and 5 should be excluded (GFR <30cc/min)
Level of serum 25-(OH) vitamin D less than 20 ng/ml; (If vitamin deficiency has been corrected, and two tests show the level above 20 ng/ml within a month, the patient can be enrolled.)
Pre-existing hypocalcemia (Albumin-adjusted serum calcium level less than 8 mg/dl in fasting specimens) which is uncorrectable
Untreated hypercalciuria (>250 mg/24h) and hypocalciuria (<100 mg/24h). If urine calcium level of patient is less than 100 mg per 24 hours and by vitamin D treatment the problem has been solved or if urine calcium level of patient is greater than 250 mg per 24 hours, but PTH is normal, the patient can be enrolled
Presence of osteonecrosis of jaw (ONJ) risk factors including a diagnosis of cancer, poor oral hygiene, periodontal and/or dental diseases, having dentures; and comorbid disorders (anemia (hemoglobin level less than 11 g/dl, if it is corrected, patient can enter the study)
history of diseases with coagulopathy, oral and dental infection)
Malignancy
Having severe and active infections; (Severe infection is a difficult treated infection, like diabetic foot infection, but if the infection is treatable, after treatment, the patient can be enrolled.)
Being bed rest (for 2 weeks during the past 3 months)
A case in which the patient cannot take 1000 mg oral elemental calcium per day; (as supplement)
Conditions that influence bone metabolism, including hyperparathyroidism or hypoparathyroidism, hyperthyroidism or hypothyroidism, hypocalcemia, inflammatory rheumatologic diseases such as rheumatoid arthritis, Paget’s disease of bone, osteomalacia that is resistant to therapy (definition of resistant to therapy: not being responder to 1-month administration of vitamin D)
Patients will be excluded if they have one severe or more than 2 moderate vertebral fractures. (Severe fracture is defined as more than 50 percent vertebral height loss and moderate fracture is defined as 25-50 percent vertebral height loss).
Use of injectable bisphosphonates within the previous 12 months
Use of oral bisphosphonates within the previous 3 months
History of severe skeletal pain with bisphosphonates
Use of parathyroid hormone or its derivatives, systemic hormone-replacement therapy, selective estrogen-receptor modulator, calcitonin, or calcitriol within 6 weeks before study enrollment.
Use of corticosteroids (>5 mg/prednisone daily or equivalent for ≥ 3months), in the past 3 months and more
Use of heparin (more than 20,000 international units/day for 6 months and longer), in the past 6 months and more.
Patient that is possible to be administrated corticosteroids (>5 mg/prednisone daily or equivalent for ≥ 3months) or heparin (more than 20,000 international units/day for 6 months and longer) in the 18 month of the study, because of her chronic disease(s) such as allergy, asthma, coagulation disorders, should be excluded.