Patient Care for Osteoporosis

goals of osteoporosis therapy:

stop or reverse bone loss, increase bone mass, decrease osteoporotic fractures, decrease falls, pain control and improved quality of life in patients with fractures

what is primary osteoporosis?

post-menopausal (female) or age-related (female > male)

what is secondary osteoporosis?

medications, medical conditions

when should therapy be initiated for osteoporosis?

1. T-score of -2.5 or lower
2. T-score between -1.0 and -2.5 AND
• 10-year probability of a hip fracture ≥ 3% (FRAX), OR
• 10-year probability of a major osteoporosis-related fracture ≥ 20% (FRAX)
3. Fracture of the hip or vertebra regardless of BMD
4. Fracture of proximal humerus, pelvis, or distal forearm AND T-score
between -1.0 and -2.5

what are the first line treatments for patients with no prior fractures?

alendronate, denosumab, risedronate, and zoledronate

what are the alternative first-line agents for patients with no prior fractures

ibandronate and raloxifene

what are the first line agents for patients with prior fractures?

abaloparaide, denosumab, romosozumab, teriparatide, and zoledronate

what are the alternative first line agents for patients with a history of fractures?

alendronate and risendronate

when should patients be given vitamin D and calcium for osteoporosis?

patients with low BMD or osteoporosis as an adjunct therapy or patients whom osteoporosis therapy is indicated but cannot be tolerated

when should patients get DXA scans?

at baseline and then every 1-2 years while on therapy

considerations for DXA scans

changes of <3-6% at the hip and <2-4% at the spine may be due to precision error of the testing itself

when should patients get bone turnover markers (BTMs)?

NTX and CTX should be reduced after 3-6 months of antiresorptive therapy and P1NP, BSAP, and OC should increase after 1-3 months of anabolic therapy

considerations of BTMs

data do not conclusively support use in predicting fracture risk, can be used to monitor adherence/persistence to therapy, can be useful to monitor during a bisphosphonate drug holiday to suggest when therapy should be restarted

what other types of labs should be done for patients on therapy for osteoporosis?

serum calcium, eGFR/CrCl for bisphosphonates

what should be monitored in patients receiving therapy?

adherence, side effects, review risk factors and modifiable lifestyle changes/fall prevention, encourage Ca (as appropriate) and vitamin D, accurate height measurement annually

how to determine if treatment was successful for patients?

stable or increased BMD with no new fracture or fracture progression, appropriate change in BTMs

how to determine if treatment is failing for patients?

progression of BMD loss or fractures after adequate duration of therapy (at least 3-6 months)

which drug class can allow for patients to take drug holidays?

Bisphosphonates only

why can only BPs give patients a drug holiday?

all non-BP drug effects will reverse rapidly upon discontinuation

T/F: efficacy of bisphosphonates beyond 5 years is limited

true

when do bone turnover markers start to change after BP therapy discontinuation, but remain higher or similar to pre-treatment baseline values?

1-3 years after d/c

when can patients consider a drug holiday from BPs?

if patient has been on IV BPs for 3 years or 5 years on oral BPs and their disease is stable

when to consider resuming therapy after drug holidays?

if patient experiences a fracture or significant BMD loss or rise in bone resorption markers to pre-treatment levels

how can you manage treatment failures?

reassess patient adherence, then reassess for secondary causes, then intensify therapy if needed

how to intensify oral antiresorptive therapy

give injectable antiresorptive therapy

how to intensify injectable antiresorptive therapy

give injectable anabolic therapy

what is combination therapy?

simultaneous treatment with two drugs

what is sequential therapy?

monotherapy with one drug followed by monotherapy with another drug

T/F: combining agents may reduce fracture more than a single agent

true

who could benefit from combo therapy?

very high-risk patients such as those with multiple vertebral fractures

example of combo therapy:

anabolic + antiresorptive agents (teriparatide + denosumab)

what are the downsides of combo therapy?

increased costs and potential for side effects

T/F: women using HRT for menopausal symptoms or raloxifene for prevention of breast cancer may add BP, denosumab, or PTH analog

true

what are the typical sequential therapies used?

romosozumab or PTH analog (x1-2 years) followed by an antiresorptive (BP or denosumab)