Long term management of osteoporosis
Lecturer: Professor Bente L Langdahl, MD, PhD, DMSc, Aarhus University Hospital, Department of Endocrinology and Internal Medicine, Denmark
Osteoporosis is a common condition that affects many patients, the prevalence increases with increasing age. The treatment of osteoporosis comprises antiresportive and bone forming drugs. The most frequently used antiresorptive treatments comprise bisphosphonates and denosumab. The only bone forming drug available in Europe is teriparatide. None of these treatments have been tested in placebo controlled trial with a placebo comparator for more than 2-3 years, yet our patients need life-long management of their condition.
The long-term management starts with and initial plan for treatment. Important considerations include the severity of the disease, co-morbidities and patient preferences. The initial choice of treatment should be monitored. This will include compliance and response to treatment, measured as changes in bone turnover markers and/or BMD. Fracture during active treatment is always a concern – especially for the patient and treatment failure should be considered.
If the initial treatment choice is teriparatide, this should after end of treatment (1.5-2 years) be followed by treatment with a strong antiresorptive to secure and further mature the bone formed during teriparatide treatment.
If the initial treatment choice was denosumab, the treatment should be continued. There are case reports suggesting an increased risk of vertebral fractures when stopping denosumab. A transfer to bisphosphonate has been suggested as a way of diminishing this risk, however, the optimal timing of starting bisphosphonate is still unknown and investigations are ongoing.
If the initial treatment choice was alendronate or zoledronic acid, a treatment break can be considered after 5 or 3 years, respectively. It is only recommended to consider treatment breaks if the patient never had suffered a vertebral fracture, had not suffered any fracture during the treatment period and has a BMD T-score at the hip above -2.5. The best follow-up strategy during treatment break is not clear; biochemical markers of bone turnover and/or BMD.
New bone forming treatments are underway; abaloparatide and romosozumab that may increase the possibility of treating patients to a treatment goal, for example a hip BMD above -1.5 or -2, a level that has been shown to be associated with a very low risk of non-vertebral fractures.
Professor Kerstin Brismar