8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
1/13
Treatment of Osteoporosis
Harold Rosen
Ian Reid
Gordon J Strewler
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
2/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
3/13
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.
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
4/13
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.
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
5/13
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.
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
6/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
7/13
Antiresorptive
Bisphosphonates
alendronate, risedronate, ibandronate, etidronate
SERMs (Selective estrogen receptor modulators)
raloxifene
Estrogen
Calcitonin
Anabolic
PTH
Drug Treatments for Osteoporosis
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
8/13
Bisphosphonates Inhibit Bone Resorption by Preventing
Formation of the Ruffled Border
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
9/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
10/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
11/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
12/13
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
8/8/2019 BoneKEy Intro Osteoporosis Treatment (1)
13/13
Top Related