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Osteoporosis Treatments and Adverse Events
for
Osteoporosis Master Class
Dr Mary BrownConsultant Rheumatologist17 May 2019
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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
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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
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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
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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
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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
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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
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Calcium & Vitamin D
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Calcium Calculator
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Prescribe a calcium supplementif intake
Ca <1200mg/day
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Calcium & Vitamin DConsider:
“caplets” or effervescent Rxs
Vit D alone (Fultium, Stexerol)
high dose Vit D
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Calcium & Vitamin DConsider:
“caplets” or effervescent Rxs
Vit D alone (Fultium, Stexerol)
high dose Vit D
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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
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“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:
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“Don’t go back to bed or lie down!!”
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Bisphosphonates inhibit osteoclast resorption of bone
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82 y/o female23 y/o female
Femoral neck and osteoporosis
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OSTEOPOROTIC BONE
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Bone is a living tissue:
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Perforation of trabeculae
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Photo reproduced with permission. © A. Boyde, QMUL.
Osteoclast
Bone Surface Resorbed by Osteoclast
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Patients` biggest fear?
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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
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Atypical Femoral Fractures (AFFs)
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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
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Subtrochanteric Fractures
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STOP BISPHOSPHONATE & XRAY CONTRALATERAL THIGH.
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AFFs - PREVENTION
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AFFs - PREVENTION
• Appropriate Rx bisphos. (FRAX score)
(NB 2 atypical #s with denosumab)
• Teriparatide if high fracture risk
• “Drug holidays” for lower risk pts
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DRUG HOLIDAYS
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Not all patients should stop bisphosphonates after 5 years.
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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
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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