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