BoneKEy Intro Osteoporosis Treatment (1)

8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)

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Treatment of Osteoporosis

Harold Rosen

Ian Reid

Gordon J Strewler


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Fracture Risk Reduction in Osteoporosis

Bone loss/low BMDCalcium/D deficiency

Estrogen deficiency

Tendency to fall

Muscle weakness

Poor balance

Preserve/increase BMDCalcium/D supplementation

Drug therapy

Fall prevention

Strengthening exercises, vit D

Balance exercise

Risk Factors Therapies


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Calcium and Vitamin D for the Treatment of

Osteoporosis

Chapuy, M. C., et al. N Engl J Med 1992 327:1637-42, with permission, Copyright 1992 Massachusetts Medical Society. All rights reserved.Dawson-Hughes, B., et al. N Engl J Med 1997 337:670-6, with permission, Copyright 1997 Massachusetts Medical Society. All rights reserved.


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Changes in BMD with Calcium + Vitamin D

Chapuy et al, N Engl J Med 1992;327:1637, with permission, Copyright 1992 Massachusetts

Medical Society. All rights reserved.Dawson-Hughes et al, N Engl J Med 1997;337:670, with permission, Copyright 1997Massachusetts Medical Society. All rights reserved.

-1.0*-6.4Trochanter

+2.7*-4.6Total Hip

+2.9*+1.8Fem Neck

Ca/DPlaceboSite

+0.06*-1.09Total body

+2.12*+1.22Spine (L2-4)

+0.50*-0.70Fem Neck

Ca/DPlaceboSite

*p < 0.05 *p < 0.05

Chapuy et al. Dawson-Hughes et al.


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Vitamin D Prevents Falls: Meta-analysis

(95% Cl)

0.47 (0.20-1.10)

0.68 (0.30-1.54)

0.53 (0.32-0.88)

0.69 (0.41-1.16)

0.91 (0.59-1.40)

0.69 (0.53-0.88)

Odds RatioSource

Pfeifer et al, 2000

Bischoff et al, 2003

Gallagher et at, 2001

Dukas et al, 2004

Graafmans et al, 1996

Pooled (Uncorrected)

Odds Ratio

Favors

Control

Favors

Vitamin D

0.1 0.5 1.0 5.0 10.0

Redrawn from Bischoff-Ferrari H et al JAMA. 2004 Apr 28;291(16):1999-2006, with permission,Copyright 2004 American Medical Association. All rights reserved.


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NOF AACE NAMS

Prior fragility

fracture

Vertebral or hip Any fracture

With low BMD

Vertebral only

T-score

Without risk

factor

< -2.0 < -2.5 < -2.5

With risk

factor

< -1.5 < -1.5 < -2.0

Risk factors 5 Major,

8 Additional

Several, including

risk of falling

Thin, family history,

prior fracture

Indications for Treatment of Postmenopausal Osteoporosis

in Three US Guidelines


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Antiresorptive

Bisphosphonates

alendronate, risedronate, ibandronate, etidronate

SERMs (Selective estrogen receptor modulators)

raloxifene

Estrogen

Calcitonin

Anabolic

PTH

Drug Treatments for Osteoporosis


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Bisphosphonates Inhibit Bone Resorption by Preventing

Formation of the Ruffled Border


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Effect of Different Drugs for Osteoporosis

on BMD and Vertebral Fracture Risk

Modified from Marcus R, et al. Endocr Rev 2002 23:16-37, with permission, Copyright 2002, The Endocrine Society.

0 1 2 3 4 5 6 7 8

Alendronate 5/10 mg

Prevalent VFx

Alendronate 5/10 mg

No Prevalent VFx

Risedronate 5mg

North American

Risedronate 5mg

Multinational

Raloxifene 60 mg

Prevalent VFxRaloxifene 60 mg

No Prevalent VFx

Nasal Calcitonin 200IU

Relative Risk of Incident Vertebral Fractures

0.2 0.4 0.6 0.8 1.0Relative Risk s 95% CI

Lumbar Spine BMD

Mean % Change from Placebo

Teriparatide 20 Qg

Ibandronate 2.5mg

Strontium Ranelate*

{

Zoledronic Acid


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Effect of Different Drugs for Osteoporosis on

Non-Vertebral Fracture Risk

Modified from Marcus R, et al. Endocr Rev. 2002 23:16-37, with permission, Copyright 2002, The Endocrine Society.

Relative Risk Incident Non-Vertebral Fractures

Nasal Calcitonin 200IUPrevalent VFx

Risedronate 2.5 & 5mg

Osteoporosis

Risedronate 5mg

Prevalent VFx

Risedronate 5mg

Prevalent VFx

Alendronate 10mgLow BMD

Alendronate 5/10mg

No Prevalent VFx

Alendronate 5/10mg

Prevalent VFx

Raloxifene 60 & 120 mg

Prevalent & No Prevalent VFx

0.2 0.4 0.6 0.8 1.0 1.2 1.4Relative Risk s 95% CI

Teriparatide 20Qg

Prevalent VFx

Strontium Ranelate*

Ibandronate

Zoledronic Acid


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Quality of evidence for antifracture efficacy of therapies

in postmenopausal osteoporosis

-AATeriparatide

-AAStrontium ranelate

AAARisedronate

--ARaloxifene

AAAEstrogen

--AIbandronate

DDBCyclic etidronate

CC-Calcium + vitamin D

-CCCalcitriol

DCCCalcitonin

AAAAlendronate

HIPNON-VERTEBRALSPINE

A, Large RCT; B, Small RCT; C, RCT are inconsistent; D, Observational studiesUpdated from WHO Osteoporosis Taskforce Report (WHO 2003), with permission, copyright 2003 World Health Organization.

AAAZoledronic acid


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Minimal follow-up

Verify that patient is taking the medication

Verify appropriate dosing procedure for bisphosphonates

Verify that patient is taking sufficient calcium and vitamin D

Optional

Bone density not usually before 2 years

Bone turnover markers role is uncertain- some physicians use them to confirm compliance, but

biological and measurement variation are a problem

Follow-up of Patients on Treatment for Osteoporosis


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BoneKEy Intro Osteoporosis Treatment (1)