DESTIN, Fla. — Among previously untreated patients with osteoporosis who are at high risk for fracture, proactive therapy with anabolic agents, followed by sequential monotherapy with denosumab, can minimize pharmacology exposure while maximizing benefits to bone mineral density and strength, according to findings presented at the 2018 Congress of Clinical Rheumatology.
“This does not mean that other therapies do not work — they do,” Felicia Cosman, MD, a professor of medicine at Columbia University, osteoporosis specialist and endocrinologist at Helen Hayes Hospital and editor in chief for North America at Osteoporosis International, told attendees. “However, anabolics work better, and I think there is a growing consensus of opinion among the bone experts, in this country, in Europe and in Asia, that this is the ideal way to go. It may be a little more expensive out front, but ultimately it is going to save money and, most importantly, going to save fractures, save disability and keep people independent and mobile.”
According to Cosman, anabolic agents, such as teriparatide and abaloparatide (Tymlos, Radius Health), are more effective as an early treatment than antiresorptive drugs, as anabolics produce more rapid results against all clinical and nonvertebral fractures — with a 43% to 86% reduction in fractures reported within 18 to 19 months. In contrast, antiresorptive drugs reduce the risk of fractures by 20% to 25% “at best,” Cosman said, and can require 3 years of treatment before patients see a significant risk reduction.
In addition, Cosman said the effect of anabolic treatment against nonvertebral fractures is greater than even the best antiresorptive drugs, and produces sustained reductions in the risk for fractures even after transition to antiresorptive therapy.
Cosman noted that the greatest gains in bone mineral density were seen in patients who used anabolic therapy as a first-line treatment followed by a potent antiresorptive agent. She added that using denosumab as a second-line antiresorptive treatment can produce a fracture-free interval of 3 to 5 years, and can help patients achieve their bone-mineral-density goals.
“I think that we want to make sure we follow the optimal treatment sequence if we can, or at least we should agree that this is something to aim for,” Cosman said. “Beginning with an anabolic, followed by, usually, denosumab and then ultimately switching to an intermittent bisphosphonate — that is the winning sequence. Ultimately, I think we can minimize the amount of time people need to be on drugs if we do it the right way. Also, this way, I think we can maximize benefits and minimize disabilities.” – by Jason Laday
Cosman F. Optimal treatment and strategies for patients at high risk of fracture. Presented at: Congress of Clinical Rheumatology; May 17-20, 2018; Destin, Florida.
Disclosure: Cosman reports speaking and advising fees, as well as research grants and medication from Amgen; advising and speaking fees, as well as research medication from Eli Lilly; advising fees from Merck; consulting, advising and speaking fees from Radius; and consulting fees from Tarsa.