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Osteoporosis Treatments and Adverse Events
for
Osteoporosis Master Class
Dr Mary BrownConsultant Rheumatologist17 May 2019
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Treatments for osteoporosis• Calcium and vitamin D• (HRT)• Raloxifene• Alendronate• Risedronate• Ibandronate (IV and oral)• IV zoledronate• (Calcitonin)• Calcitriol• Denosumab
• Teriparatide
• (Strontium Ranelate)
Antiresorptives
Anabolic
? action
Calcium & Vitamin D
Calcium Calculator
Prescribe a calcium supplementif intake
Ca <1200mg/day
Calcium & Vitamin DConsider:
“caplets” or effervescent Rxs
Vit D alone (Fultium, Stexerol)
high dose Vit D
Calcium & Vitamin DConsider:
“caplets” or effervescent Rxs
Vit D alone (Fultium, Stexerol)
high dose Vit D
Why is compliance so poor?
• Osteoporosis is a silent condition• Patient`s beliefs/perception of fracture
risk• Actual side effects – GI, arthralgia• Fear of potential side effects• Memory impairment• Special requirements for dosing
“Take the medication 30-60 minutes before breakfast, On an empty stomach with a full
glass of plain tap water; Don`t take any other food, drink
or medications for at least half an hour;
• Remain upright and…….
Patients on oral bisphosphonates are instructed to:
“Don’t go back to bed or lie down!!”
Bisphosphonates inhibit osteoclast resorption of bone
82 y/o female23 y/o female
Femoral neck and osteoporosis
OSTEOPOROTIC BONE
Bone is a living tissue:
Perforation of trabeculae
Photo reproduced with permission. © A. Boyde, QMUL.
Osteoclast
Bone Surface Resorbed by Osteoclast
Patients` biggest fear?
Osteonecrosis of the Jaw (ONJ)• < 1/100,000 pt yrs (in osteoporosis)• ↑ risk with iv bisphosphonates
poor oral hygienediabetescorticosteroidsmalignancy
• N.B. occurs with d`mab, thalidomide & antiVEGF injections and non-osteoporotics
• Dose-related (rather than duration- associated)
Dental check before and during Rx
Atypical Femoral Fractures (AFFs)
AFFs - Typical Presentation• 0.3 - 1 /1,000 pt yrs • Minimal or no trauma• Noncomminuted• Prodromal thigh pain (64%)• Poor healing (25%)• Bilateral (70%)• >5 yrs bisphosphonate Rx• Assoc. with RA, steroids, PPIs, ↓ Vit D ,
higher BMDShane et al , JBMR 2014
Subtrochanteric Fractures
STOP BISPHOSPHONATE & XRAY CONTRALATERAL THIGH.
AFFs - PREVENTION
AFFs - PREVENTION
• Appropriate Rx bisphos. (FRAX score)
(NB 2 atypical #s with denosumab)
• Teriparatide if high fracture risk
• “Drug holidays” for lower risk pts
DRUG HOLIDAYS
Not all patients should stop bisphosphonates after 5 years.
Drug Holidays• Consider if fracture-free after 5yrs Rx• Review initial indication• Reassess current fracture risk (? T-score >-2.5)
NOT for pts with hip & vertebral #sv. low T-scores>75 yrs + >7.5 mg pred.
P9, Executive Summary, Osteoporosis Clinical Guideline, May 2013, NOGG Guideline 2017
Take Home Messages• T score -2.5 does not necessarily mean treatment – do a
FRAX score
• Steroids do not necessarily = a bisphosphonate – do a FRAX score
• Not all patients should stop bisphosphonates after 5 years.
• Investigate thigh pain in patients on long term bisphosphonates