Osteoporosis medical therapy: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 27: Line 27:
{{Family tree | | | | | | | C01 | | C02 | | | | |C04|C01= For patients with CrCl 15–30 mL/min <br>'''Recommend:'''<br>• Denosumab<br>(60 mg subcutaneously twice yearly)<br>'''Remarks:'''<br>• Monitor calcium levels, given higher risk of hypocalcemia <br>• Bisphosphonate therapies are not recommended <br>• Consider referral to specialist|C02='''Recommend:'''<br>• Denosumab<br>(60 mg subcutaneously twice yearly)<br>• Zoledronic acid<br>(5 mg IV once yearly)<br> '''Suggest:'''<br>• Teriparatide<br>(20 mcg subcutaneously daily)|C04='''Recommend:'''<br>• Alendronate (70 mg weekly)<br>• Risedronate (35 mg weekly or 150 mg monthly)<br>• Denosumab (60 mg subcutaneously twice yearly)<br>• Zoledronic acid (5 mg IV once yearly)<br> '''Suggest:'''<br>• Teriparatide (20 mcg subcutaneously daily)}}
{{Family tree | | | | | | | C01 | | C02 | | | | |C04|C01= For patients with CrCl 15–30 mL/min <br>'''Recommend:'''<br>• Denosumab<br>(60 mg subcutaneously twice yearly)<br>'''Remarks:'''<br>• Monitor calcium levels, given higher risk of hypocalcemia <br>• Bisphosphonate therapies are not recommended <br>• Consider referral to specialist|C02='''Recommend:'''<br>• Denosumab<br>(60 mg subcutaneously twice yearly)<br>• Zoledronic acid<br>(5 mg IV once yearly)<br> '''Suggest:'''<br>• Teriparatide<br>(20 mcg subcutaneously daily)|C04='''Recommend:'''<br>• Alendronate (70 mg weekly)<br>• Risedronate (35 mg weekly or 150 mg monthly)<br>• Denosumab (60 mg subcutaneously twice yearly)<br>• Zoledronic acid (5 mg IV once yearly)<br> '''Suggest:'''<br>• Teriparatide (20 mcg subcutaneously daily)}}


{{Family tree/end}}
{{Family tree/end}}Most of the time in high risk patients and people with past history of [[Osteoporosis|osteoporotic]] [[fracture]], [[Medical therapy template|medical therapy]] is necessary.<ref name="pmid28780668">{{cite journal| author=Minisola S, Cipriani C, Occhiuto M, Pepe J| title=New anabolic therapies for osteoporosis. | journal=Intern Emerg Med | year= 2017 | volume=  | issue=  | pages=  | pmid=28780668 | doi=10.1007/s11739-017-1719-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28780668  }}</ref>
 
* Most of the time in high risk patients and people with past history of [[Osteoporosis|osteoporotic]] [[fracture]], [[Medical therapy template|medical therapy]] is necessary.<ref name="pmid28780668">{{cite journal| author=Minisola S, Cipriani C, Occhiuto M, Pepe J| title=New anabolic therapies for osteoporosis. | journal=Intern Emerg Med | year= 2017 | volume=  | issue=  | pages=  | pmid=28780668 | doi=10.1007/s11739-017-1719-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28780668  }}</ref>


=== Medical therapy purpose ===
=== Medical therapy purpose ===
Line 42: Line 40:
** Elder man and [[postmenopausal]] women with -1.0 > T-score > -2.5 SD with high risk of [[Osteoporosis|osteoporotic]] [[Bone fracture|fracture]]
** Elder man and [[postmenopausal]] women with -1.0 > T-score > -2.5 SD with high risk of [[Osteoporosis|osteoporotic]] [[Bone fracture|fracture]]
** Men with [[hypogonadism]] that [[testosterone]] therapy is contraindicated<ref name="pmid28761958" />
** Men with [[hypogonadism]] that [[testosterone]] therapy is contraindicated<ref name="pmid28761958" />
* The international osteoporosis foundation (IOF) suggested that postmenopausal women and men age 50 and older presenting with the following should be considered for treatment:  
* The international [[osteoporosis]] foundation (IOF) suggested that [[postmenopausal]] women and men age 50 and older presenting with the following should be considered for treatment:  
** A hip or vertebral fracture (clinically apparent or found on vertebral imaging). There are abundant data that patients with spine and hip fractures will have reduced fracture risk if treated with pharmacologic therapy. This is true for fracture patients with BMD in both the low bone mass and osteoporosis range . In patients with a hip or spine fracture, the T-score is not as important as the fracture itself in predicting future risk of fracture and antifracture efficacy from treatment.
** A [[hip]] or [[vertebral fracture]] (clinically apparent or found on [[vertebral]] imaging). There are abundant data that patients with [[spine]] and [[hip fractures]] will have reduced fracture risk if treated with [[pharmacologic]] [[therapy]]. This is true for [[fracture]] patients with [[Bone mineral density|BMD]] in both the low [[bone mass]] and [[osteoporosis]] range . In patients with a [[Hip Fractures|hip]] or [[spine]] [[fracture]], the T-score is not as important as the [[fracture]] itself in predicting [[future]] risk of [[fracture]] and antifracture efficacy from treatment.
** T-score ≤−2.5 at the femoral neck, total hip, or lumbar spine. There is abundant evidence that the elevated risk of fracture in patients with osteoporosis by BMD is reduced with pharmacotherapy [52, 57, 59–70].
** T-score ≤−2.5 at the [[femoral neck]], total [[hip]], or [[lumbar spine]]. There is abundant evidence that the elevated risk of [[fracture]] in patients with [[osteoporosis]] by [[Bone mineral density|BMD]] is reduced with [[pharmacotherapy]].
** Low bone mass (T-score between −1.0 and −2.5 at the femoral neck or lumbar spine) and a 10-year probability of a hip fracture ≥3 % or a 10-year probability of a major osteoporosis-related fracture ≥20 % based on the US adapted WHO algorithm.<ref name="Cosmande Beur2014">{{cite journal|last1=Cosman|first1=F.|last2=de Beur|first2=S. J.|last3=LeBoff|first3=M. S.|last4=Lewiecki|first4=E. M.|last5=Tanner|first5=B.|last6=Randall|first6=S.|last7=Lindsay|first7=R.|title=Clinician’s Guide to Prevention and Treatment of Osteoporosis|journal=Osteoporosis International|volume=25|issue=10|year=2014|pages=2359–2381|issn=0937-941X|doi=10.1007/s00198-014-2794-2}}</ref>
** Low [[bone mass]] (T-score between −1.0 and −2.5 at the [[femoral neck]] or [[lumbar spine]]) and a 10-year probability of a [[hip fracture]] ≥3 % or a 10-year probability of a major [[osteoporosis]]-related [[fracture]] ≥20 % based on the US adapted WHO algorithm.<ref name="Cosmande Beur2014">{{cite journal|last1=Cosman|first1=F.|last2=de Beur|first2=S. J.|last3=LeBoff|first3=M. S.|last4=Lewiecki|first4=E. M.|last5=Tanner|first5=B.|last6=Randall|first6=S.|last7=Lindsay|first7=R.|title=Clinician’s Guide to Prevention and Treatment of Osteoporosis|journal=Osteoporosis International|volume=25|issue=10|year=2014|pages=2359–2381|issn=0937-941X|doi=10.1007/s00198-014-2794-2}}</ref>


=== Medical therapy options ===
=== Medical therapy options ===
Line 51: Line 49:
* 1.1 '''Improving bone mineral density (BMD)'''
* 1.1 '''Improving bone mineral density (BMD)'''
** 1.1.1 '''Adult'''
** 1.1.1 '''Adult'''
*** Preferred regimen (1): Alendronate 70 mg PO weekly 
*** Preferred regimen (1): [[Alendronate]] 70 mg PO weekly 
*** Preferred regimen (2): Risedronate 35 mg PO weekly OR 150 mg PO monthly
*** Preferred regimen (2): [[Risedronate]] 35 mg PO weekly OR 150 mg PO monthly
*** Preferred regimen (3): Ibandronate 150 mg PO monthly OR 3 mg IV every 3 months
*** Preferred regimen (3): [[Ibandronate]] 150 mg PO monthly OR 3 mg IV every 3 months
*** Preferred regimen (4): Zoledronic acid 5 mg IV annually  
*** Preferred regimen (4): [[Zoledronic acid]] 5 mg IV annually  
*** Alternative regimen (1): Raloxifen 60 mg PO daily
*** Alternative regimen (1): [[Raloxifene]] 60 mg PO daily
*** Alternative regimen (2): Denosumab 60 mg SC every 6 months
*** Alternative regimen (2): [[Denosumab]] 60 mg SC every 6 months
*** Alternative regimen (3): Romosozumab 210 mg SC monthly
*** Alternative regimen (3): Romosozumab 210 mg SC monthly
*** Alternative regimen (4): Teriparatide 20 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (4): [[Teriparatide]] 20 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (3): Calcitonin 100 units SC daily OR 200 units intranasal daily
*** Alternative regimen (3): [[Calcitonin]] 100 units SC daily OR 200 units intranasal daily


==== Anti-fracture efficacy of approved treatments for postmenopausal women with osteoporosis when given with calcium and vitamin D<ref name="pmid25182228" /> ====
==== Anti-fracture efficacy of approved treatments for postmenopausal women with osteoporosis when given with calcium and vitamin D<ref name="pmid25182228" /> ====
Line 133: Line 131:
* 2.1 '''Improving bone mineral density (BMD)'''
* 2.1 '''Improving bone mineral density (BMD)'''
** 2.1.1 '''Adult'''
** 2.1.1 '''Adult'''
*** Preferred regimen (1): Alendronate 70 mg PO weekly 
*** Preferred regimen (1): [[Alendronate]] 70 mg PO weekly 
*** Preferred regimen (2): Risedronate 35 mg PO weekly OR 150 mg PO monthly
*** Preferred regimen (2): [[Risedronate]] 35 mg PO weekly OR 150 mg PO monthly
*** Preferred regimen (3): Ibandronate 150 mg PO monthly OR 3 mg IV every 3 months
*** Preferred regimen (3): [[Ibandronate]] 150 mg PO monthly OR 3 mg IV every 3 months
*** Preferred regimen (4): Zoledronic acid 5 mg IV annually  
*** Preferred regimen (4): [[Zoledronic acid]] 5 mg IV annually  
*** Alternative regimen (1): Raloxifen 60 mg PO daily
*** Alternative regimen (1): [[Raloxifene]] 60 mg PO daily
*** Alternative regimen (2): Denosumab 60 mg SC every 6 months
*** Alternative regimen (2): [[Denosumab]] 60 mg SC every 6 months
*** Alternative regimen (3): Romosozumab 210 mg SC monthly
*** Alternative regimen (3): Romosozumab 210 mg SC monthly
*** Alternative regimen (4): Teriparatide 20 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (4): [[Teriparatide]] 20 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
*** Alternative regimen (3): Calcitonin 100 units SC daily OR 200 units intranasal daily
*** Alternative regimen (3): [[Calcitonin]] 100 units SC daily OR 200 units intranasal daily


==== Recommendations for initial treatment for glucocorticoid induced osteoporosis in adults by American College of Rheumatology (ACR), 2017<ref name="BuckleyGuyatt2017">{{cite journal|last1=Buckley|first1=Lenore|last2=Guyatt|first2=Gordon|last3=Fink|first3=Howard A.|last4=Cannon|first4=Michael|last5=Grossman|first5=Jennifer|last6=Hansen|first6=Karen E.|last7=Humphrey|first7=Mary Beth|last8=Lane|first8=Nancy E.|last9=Magrey|first9=Marina|last10=Miller|first10=Marc|last11=Morrison|first11=Lake|last12=Rao|first12=Madhumathi|last13=Robinson|first13=Angela Byun|last14=Saha|first14=Sumona|last15=Wolver|first15=Susan|last16=Bannuru|first16=Raveendhara R.|last17=Vaysbrot|first17=Elizaveta|last18=Osani|first18=Mikala|last19=Turgunbaev|first19=Marat|last20=Miller|first20=Amy S.|last21=McAlindon|first21=Timothy|title=2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis|journal=Arthritis & Rheumatology|volume=69|issue=8|year=2017|pages=1521–1537|issn=23265191|doi=10.1002/art.40137}}</ref> ====
==== Recommendations for initial treatment for glucocorticoid induced osteoporosis in adults by American College of Rheumatology (ACR), 2017<ref name="BuckleyGuyatt2017">{{cite journal|last1=Buckley|first1=Lenore|last2=Guyatt|first2=Gordon|last3=Fink|first3=Howard A.|last4=Cannon|first4=Michael|last5=Grossman|first5=Jennifer|last6=Hansen|first6=Karen E.|last7=Humphrey|first7=Mary Beth|last8=Lane|first8=Nancy E.|last9=Magrey|first9=Marina|last10=Miller|first10=Marc|last11=Morrison|first11=Lake|last12=Rao|first12=Madhumathi|last13=Robinson|first13=Angela Byun|last14=Saha|first14=Sumona|last15=Wolver|first15=Susan|last16=Bannuru|first16=Raveendhara R.|last17=Vaysbrot|first17=Elizaveta|last18=Osani|first18=Mikala|last19=Turgunbaev|first19=Marat|last20=Miller|first20=Amy S.|last21=McAlindon|first21=Timothy|title=2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis|journal=Arthritis & Rheumatology|volume=69|issue=8|year=2017|pages=1521–1537|issn=23265191|doi=10.1002/art.40137}}</ref> ====
Line 265: Line 263:
=== Non-FDA-approved drugs for osteoporosis ===
=== Non-FDA-approved drugs for osteoporosis ===
Nonapproved agents include:
Nonapproved agents include:
* '''Calcitriol''': This synthetic vitamin D analogue, which promotes calcium absorption, has been approved by the FDA for managing hypocalcemia and metabolic bone disease in renal dialysis patients. It is also approved for use in hypoparathyroidism, both surgical and idiopathic, and pseudohypoparathyroidism. No reliable data demonstrate a reduction of risk for osteoporotic fracture.  
* '''Calcitriol''': This synthetic [[vitamin D]] analogue, which promotes [[calcium]] absorption, has been approved by the [[FDA]] for managing [[hypocalcemia]] and metabolic [[bone]] [[disease]] in renal [[dialysis]] patients. It is also approved for use in [[hypoparathyroidism]], both surgical and [[idiopathic]], and [[pseudohypoparathyroidism]]. No reliable data demonstrate a reduction of risk for osteoporotic [[fracture]].  
* '''Genistein''': An isoflavone phytoestrogen which is the main ingredient in the prescription “medical food” product Fosteum® and generally regarded as safe by the FDA. Genistein may benefit bone health in postmenopausal women but more data are needed to fully understand its effects on bone health and fracture risk.  
* '''Genistein''': An [[isoflavone]] [[phytoestrogen]] which is the main ingredient in the prescription “medical food” product Fosteum® and generally regarded as safe by the FDA. [[Genistein]] may benefit [[bone]] health in [[postmenopausal]] women but more data are needed to fully understand its effects on [[bone]] health and [[fracture]] risk.  
* '''Other bisphosphonates (etidronate, pamidronate, tiludronate)''': These medications vary chemically from alendronate, ibandronate, risedronate, and zoledronic acid but are in the same drug class. At this time, none is approved for prevention or treatment of osteoporosis. Most of these medications are currently approved for other conditions (e.g., Paget’s disease, hypercalcemia of malignancy, myositis ossificans).  
* '''Other bisphosphonates (etidronate, pamidronate, tiludronate)''': These medications vary chemically from [[alendronate]], [[ibandronate]], [[risedronate]], and [[zoledronic acid]] but are in the same drug class. At this time, none is approved for prevention or treatment of [[osteoporosis]]. Most of these medications are currently approved for other conditions (e.g., [[Paget’s disease]], [[hypercalcemia]] of [[malignancy]], [[myositis ossificans]]).  
* '''PTH (1-84)''': This medication is approved in some countries in Europe for treatment of osteoporosis in women. In one clinical study, PTH(1-84) effectively reduced the risk of vertebral fractures at a dose of 100 mcg/ day.  
* '''PTH (1-84)''': This [[medication]] is approved in some countries in Europe for treatment of [[osteoporosis]] in women. In one clinical study, [[PTH]] (1-84) effectively reduced the risk of [[vertebral fractures]] at a dose of 100 mcg/ day.  
* '''Sodium fluoride''': Through a process that is still unclear, sodium fluoride stimulates the formation of new bone. The quality of bone mass thus developed is uncertain, and the evidence that fluoride reduces fracture risk is conflicting and controversial.  
* '''Sodium fluoride''': Through a process that is still unclear, [[sodium fluoride]] stimulates the formation of new [[bone]]. The quality of [[bone mass]] thus developed is uncertain, and the evidence that [[fluoride]] reduces [[fracture]] risk is conflicting and controversial.  
* '''Strontium ranelate''': This medication is approved for the treatment of osteoporosis in some countries in Europe. Strontium ranelate reduces the risk of both spine and nonvertebral fractures, but the mechanism is unclear. Incorporation of strontium into the crystal structure replacing calciummay be part of itsmechanism of effect. These effects have only been documented with the pharmaceutical grade agent produced by Servier. This effect has not been studied in nutritional supplements containing strontium salts.  
* '''Strontium ranelate''': This medication is approved for the treatment of [[osteoporosis]] in some countries in Europe. [[Strontium ranelate]] reduces the risk of both [[spine]] and nonvertebral [[fractures]], but the mechanism is unclear. Incorporation of [[strontium]] into the crystal structure replacing [[calcium]] may be part of its mechanism of effect. These effects have only been documented with the [[pharmaceutical]] grade agent produced by [[Servier Laboratories|Servier]]. This effect has not been studied in nutritional supplements containing [[strontium]] salts.  
* '''Tibolone''': Tibolone is a tissue-specific, estrogen-like agent that may prevent bone loss and reduce menopausal symptoms. It is indicated in Europe for the treatment of vasomotor symptoms of menopause and for prevention of osteoporosis, but it is not approved for use in the USA.<ref name="Cosmande Beur2014" />
* '''Tibolone''': [[Tibolone]] is a tissue-specific, [[estrogen]]-like agent that may prevent [[bone loss]] and reduce [[menopausal]] symptoms. It is indicated in Europe for the treatment of [[vasomotor]] symptoms of [[menopause]] and for prevention of [[osteoporosis]], but it is not approved for use in the USA.<ref name="Cosmande Beur2014" />


==References==
==References==

Revision as of 22:07, 16 August 2017

Osteoporosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Osteoporosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Life Style Modification
Pharmacotherapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Osteoporosis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Osteoporosis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Osteoporosis medical therapy

CDC on Osteoporosis medical therapy

Osteoporosis medical therapy in the news

Blogs on Osteoporosis medical therapy

Directions to Hospitals Treating Osteoporosis

Risk calculators and risk factors for Osteoporosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

The mainstays of treatment in primary osteoporosis disease are based on in life style modifications. Most of the time in high risk patients and people with past history of osteoporotic fracture, medical therapy is necessary. Bisphosphonates are the first line treatment for osteoporosis disease. Raloxifene is the second line treatment of osteoporosis in postmenopausal women, for both treatment and prevention. Denosumab is a human monoclonal antibody designed to inhibit RANKL (RANK ligand), a protein that acts as the primary signal for bone removal. It is used to treat Osteoporosis in elder men and postmenopausal women. Teriparatide and Abaloparatide are human recombinant parathyroid hormones used to treat postmenopausal woman with osteoporosis at high risk of fracture or to increase bone mass in men with osteoporosis.

Medical therapy

Fracture prevention medical therapy algorithm[1]

 
 
Strategies to prevent fractures and falls

Recommend:
• Dietary calcium 1200 mg/day

Suggest:
• Vitamin D (≥ 800–2000 IU/day)
• Calcium supplement≤ 500 mg, if dietary calcium not met
• Hip protectors
• Multifactorial fall-prevention strategies:
1. Exercise (balance, strength and functional training)
2. Medication reviews (e.g., Beers criteria)
3. Assessment of environmental hazards
4. Use of assistive devices
5. Management of urinary incontinence
 
 
 
 
 
 
 
Fracture risk assessment on admission
• Prior hip fracture?
• Prior vertebral fracture?
• More than one prior fracture (excluding hands, feet, ankles)?
• Recent use of glucocorticoid and one prior fracture (excluding hands, feet, ankles)?
• Assessed as high risk for fracture and receiving fracture treatment before admission?
• Vertebral fracture present? (if chest radiography ordered, screen for vertebral fractures)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient has a fracture, reassess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If “yes’ to any of the above,
patient is considered as high risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recommend:
• Dietary calcium 1200 mg/day
• Vitamin D supplements (800–2000 IU/day)
• Calcium supplements ≤ 500 mg, if dietary calcium not met
• Hip protectors for mobile residents

Suggest:
• Exercise program only as part of multifactorial fracture and fall prevention program
 
 
 
 
 
 
Pharmacologic therapy not appropriate
 
No
 
Is patient expected to live > 1 year?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is CrCl > 30 mL/min?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
Does patient have dysphagia?
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
For patients with CrCl 15–30 mL/min
Recommend:
• Denosumab
(60 mg subcutaneously twice yearly)
Remarks:
• Monitor calcium levels, given higher risk of hypocalcemia
• Bisphosphonate therapies are not recommended
• Consider referral to specialist
 
Recommend:
• Denosumab
(60 mg subcutaneously twice yearly)
• Zoledronic acid
(5 mg IV once yearly)
Suggest:
• Teriparatide
(20 mcg subcutaneously daily)
 
 
 
 
Recommend:
• Alendronate (70 mg weekly)
• Risedronate (35 mg weekly or 150 mg monthly)
• Denosumab (60 mg subcutaneously twice yearly)
• Zoledronic acid (5 mg IV once yearly)
Suggest:
• Teriparatide (20 mcg subcutaneously daily)

Most of the time in high risk patients and people with past history of osteoporotic fracture, medical therapy is necessary.[2]

Medical therapy purpose

Medical therapy candidates

Medical therapy options

1 Stage 1 - Osteoporosis

  • 1.1 Improving bone mineral density (BMD)
    • 1.1.1 Adult
      • Preferred regimen (1): Alendronate 70 mg PO weekly 
      • Preferred regimen (2): Risedronate 35 mg PO weekly OR 150 mg PO monthly
      • Preferred regimen (3): Ibandronate 150 mg PO monthly OR 3 mg IV every 3 months
      • Preferred regimen (4): Zoledronic acid 5 mg IV annually
      • Alternative regimen (1): Raloxifene 60 mg PO daily
      • Alternative regimen (2): Denosumab 60 mg SC every 6 months
      • Alternative regimen (3): Romosozumab 210 mg SC monthly
      • Alternative regimen (4): Teriparatide 20 mcg SC daily, approved for less than 2 years use
      • Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
      • Alternative regimen (3): Calcitonin 100 units SC daily OR 200 units intranasal daily

Anti-fracture efficacy of approved treatments for postmenopausal women with osteoporosis when given with calcium and vitamin D[7]

Vertebral fracture Non-vertebral fracture Hip fracture
Alendronate Highly effective Highly effective Highly effective
Etidronate Highly effective Moderately effective Not adequately evaluated
Ibandronate Highly effective Highly effective Not adequately evaluated
Risedronate Highly effective Highly effective Highly effective
Zoledronic acid Highly effective Highly effective Highly effective
Denosumab Highly effective Highly effective Highly effective
Calcitriol Highly effective Moderately effective Not adequately evaluated
Raloxifene Highly effective Not adequately evaluated Not adequately evaluated
Strontium ranelate Highly effective Highly effective Highly effective
Teriparatide Highly effective Highly effective Not adequately evaluated
Recombinant human PTH (1-84) Highly effective Not adequately evaluated Not adequately evaluated
Hormone replacement therapy (HRT) Highly effective Highly effective Highly effective

2 Stage 2 - Glucocorticoid induced osteoporosis

  • 2.1 Improving bone mineral density (BMD)
    • 2.1.1 Adult
      • Preferred regimen (1): Alendronate 70 mg PO weekly 
      • Preferred regimen (2): Risedronate 35 mg PO weekly OR 150 mg PO monthly
      • Preferred regimen (3): Ibandronate 150 mg PO monthly OR 3 mg IV every 3 months
      • Preferred regimen (4): Zoledronic acid 5 mg IV annually
      • Alternative regimen (1): Raloxifene 60 mg PO daily
      • Alternative regimen (2): Denosumab 60 mg SC every 6 months
      • Alternative regimen (3): Romosozumab 210 mg SC monthly
      • Alternative regimen (4): Teriparatide 20 mcg SC daily, approved for less than 2 years use
      • Alternative regimen (5): Abaloparatide 80 mcg SC daily, approved for less than 2 years use
      • Alternative regimen (3): Calcitonin 100 units SC daily OR 200 units intranasal daily

Recommendations for initial treatment for glucocorticoid induced osteoporosis in adults by American College of Rheumatology (ACR), 2017[8]

 
 
 
 
 
 
Calcium and vitamin D and life style modification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk
 
 
 
 
 
 
 
Moderate/High risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further treatment

Monitor with yearly fracture risk assessment
with BMD testing every 2-3 years
depending on risk factors
 
 
 
 
Age < 40 years

1. History of osteoporotic fracture, OR
2. Z score < -3 at hip or spine and
prednisolone ≥ 7.5 mg/d, OR
3. >10%/year loss of BMD at hip or spine and
prednisolone ≥ 7.5 mg/d, OR
4. Very high dose glucocorticoid and > 10 years
 
 
 
Age ≥ 40 years

1. History of osteoporotic fracture, OR
2. Men > 50 years and postmenopausal women
with a BMD T-score ≤ -2.5, OR
3. FRAX 10-year risk for major osteoporotic fracture > 10%, OR
4. FRAX 10-year risk for hip osteoporotic fracture > 1%, OR
5. Very high dose of glucocorticoid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with an oral bisphosphonate

Second-line therapy: teriparatide

Other suggested therapies (in order of preference)
for high risk woman for whom the previous drugs are not appropriate:

IV bisphosphonate
Denosumab
 
 
 
Treat with an oral bisphosphonate
Other suggested therapies (in order of preference):

IV bisphosphonate
Teriparatide
Denosumab
Raloxifen for postmenopausal women if no other therapy is available
 
 
 

Effect of approved interventions for glucocorticoid-induced osteoporosis on BMD and fracture risk by National Osteoporosis Guideline Group (NOGG), UK, 2014[7]

Intervention Spine BMD Hip BMD Vertebral fracture Non-vertebral fracture
Alendronate Highly effective Highly effective Moderately effective Not adequately evaluated
Etidronate Highly effective Highly effective Highly effective Not adequately evaluated
Risedronate Highly effective Highly effective Highly effective Not adequately evaluated
Zoledronic acid Highly effective Highly effective Not adequately evaluated Not adequately evaluated
Teriparatide Highly effective Highly effective Highly effective Not adequately evaluated

Bisphosphonates

Bisphosphonates are the first line treatment for osteoporosis disease. They are not indicated in people with severe renal function impairment; thus, it is important to check renal function and serum creatinine before prescription. These drugs have to taken orally with large amount of water, not laying down until two hours following consumption, due to high risk of esophagitis. Rare but serious side effects may include osteonecrosis of the jaw and atypical femoral fractures.

National Osteoporosis Guideline Group (NOGG) algorithm for long term bisphosphonate therapy monitoring[7]

 
 
 
 
 
Advise
3 years zoledronic acid
or
5 years other bisphosphonates
(follow up at 3/12 to discuss treatment issues)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No fracture
 
 
 
 
 
 
 
Recurrent fracture(s)
Prevalent vertebral fracture(s)

In patients taking oral bisphosphonate consider continuation if:
• Age > 75 years
• Previous hip fracture
• Current oral glucocorticoid therapy ≥ 7.5 mg/d prednisolone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FRAX+BMD
after 3 years zoledronic acid
or
5 years other bisphosphonates
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Above NOGG intervention threshold
or
Hip BMD T-score ≤ -2.5
 
 
 
 
 
 
 
Below NOGG intervention threshold
or
Hip BMD T-score > -2.5
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Check adherence
2. Exclude secondary cause
3. Re-evaluate treatment choice
4. Continue treatment
 
 
 
 
 
 
 
1. Consider drug holiday
2. Repeat FRAX+BMD in 1.5-3 years
 
 
 
 

Receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor

Selective estrogen receptor modulator (SERM)

Parathyroid hormone and related peptide analogs

Calcitonin

Non-FDA-approved drugs for osteoporosis

Nonapproved agents include:

References

  1. Papaioannou A, Santesso N, Morin SN, Feldman S, Adachi JD, Crilly R, Giangregorio LM, Jaglal S, Josse RG, Kaasalainen S, Katz P, Moser A, Pickard L, Weiler H, Whiting S, Skidmore CJ, Cheung AM (2015). "Recommendations for preventing fracture in long-term care". CMAJ. 187 (15): 1135–44, E450–61. doi:10.1503/cmaj.141331. PMC 4610837. PMID 26370055.
  2. Minisola S, Cipriani C, Occhiuto M, Pepe J (2017). "New anabolic therapies for osteoporosis". Intern Emerg Med. doi:10.1007/s11739-017-1719-4. PMID 28780668.
  3. Cummings SR, Karpf DB, Harris F, Genant HK, Ensrud K, LaCroix AZ, Black DM (2002). "Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs". Am. J. Med. 112 (4): 281–9. PMID 11893367.
  4. 4.0 4.1 4.2 Ensrud KE, Crandall CJ (2017). "Osteoporosis". Ann. Intern. Med. 167 (3): ITC17–ITC32. doi:10.7326/AITC201708010. PMID 28761958.
  5. Bauer DC (2013). "Clinical practice. Calcium supplements and fracture prevention". N. Engl. J. Med. 369 (16): 1537–43. doi:10.1056/NEJMcp1210380. PMC 4038300. PMID 24131178.
  6. 6.0 6.1 6.2 Cosman, F.; de Beur, S. J.; LeBoff, M. S.; Lewiecki, E. M.; Tanner, B.; Randall, S.; Lindsay, R. (2014). "Clinician's Guide to Prevention and Treatment of Osteoporosis". Osteoporosis International. 25 (10): 2359–2381. doi:10.1007/s00198-014-2794-2. ISSN 0937-941X.
  7. 7.0 7.1 7.2 Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S; et al. (2014). "Clinician's Guide to Prevention and Treatment of Osteoporosis". Osteoporos Int. 25 (10): 2359–81. doi:10.1007/s00198-014-2794-2. PMC 4176573. PMID 25182228.
  8. Buckley, Lenore; Guyatt, Gordon; Fink, Howard A.; Cannon, Michael; Grossman, Jennifer; Hansen, Karen E.; Humphrey, Mary Beth; Lane, Nancy E.; Magrey, Marina; Miller, Marc; Morrison, Lake; Rao, Madhumathi; Robinson, Angela Byun; Saha, Sumona; Wolver, Susan; Bannuru, Raveendhara R.; Vaysbrot, Elizaveta; Osani, Mikala; Turgunbaev, Marat; Miller, Amy S.; McAlindon, Timothy (2017). "2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis". Arthritis & Rheumatology. 69 (8): 1521–1537. doi:10.1002/art.40137. ISSN 2326-5191.
  9. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD (1999). "Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group". JAMA. 282 (14): 1344–52. PMID 10527181.
  10. Chesnut CH, Skag A, Christiansen C, Recker R, Stakkestad JA, Hoiseth A, Felsenberg D, Huss H, Gilbride J, Schimmer RC, Delmas PD (2004). "Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis". J. Bone Miner. Res. 19 (8): 1241–9. doi:10.1359/JBMR.040325. PMID 15231010.
  11. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR (2007). "Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis". N. Engl. J. Med. 356 (18): 1809–22. doi:10.1056/NEJMoa067312. PMID 17476007.
  12. McClung MR, Lewiecki EM, Geller ML, Bolognese MA, Peacock M, Weinstein RL, Ding B, Rockabrand E, Wagman RB, Miller PD (2013). "Effect of denosumab on bone mineral density and biochemical markers of bone turnover: 8-year results of a phase 2 clinical trial". Osteoporos Int. 24 (1): 227–35. doi:10.1007/s00198-012-2052-4. PMC 3536967. PMID 22776860.
  13. Bandeira L, Lewiecki EM, Bilezikian JP (2017). "Romosozumab for the treatment of osteoporosis". Expert Opin Biol Ther. 17 (2): 255–263. doi:10.1080/14712598.2017.1280455. PMID 28064540.
  14. Lippuner K, Buchard PA, De Geyter C, Imthurn B, Lamy O, Litschgi M, Luzuy F, Schiessl K, Stute P, Birkhäuser M (2012). "Recommendations for raloxifene use in daily clinical practice in the Swiss setting". Eur Spine J. 21 (12): 2407–17. doi:10.1007/s00586-012-2404-y. PMC 3508239. PMID 22739699.
  15. Felsenfeld, A. J.; Levine, B. S. (2015). "Calcitonin, the forgotten hormone: does it deserve to be forgotten?". Clinical Kidney Journal. 8 (2): 180–187. doi:10.1093/ckj/sfv011. ISSN 2048-8505.

Template:WS Template:WH