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This session was an update on the management of osteoporosis given by Professor Christian Roux from France.
He emphasised the use of composite risk score like the FRAX. He highlighted that the risk of vertebral fracture is increased by both the recency and severity of previous vertebral fracture. So it is important that those with vertebral fractures are followed up and treated appropriately to prevent subsequent fractures.
He cited evidence that falls, narcotic use and advancing age all contribute to imminent risk of fracture incidence. Research on fracture liaison services has shown not only a reduction in mortality but also non-vertebral fracture, and they are cost saving. Falls prevention programmes which prescribe exercise and physical activity can reduce the risk of injury but can be hard to implement.
When considering drug treatment, the options with good evidence include alendronate, riseronate, zolendronic acid, raloxetine, teriparatide and denosumab.
More recently two studies have compared anti-osteoporotic fractures directly. The first was a study comparing risedronate to teriparatide and this showed that teriparatide treated patients treated for 12 and 24 months had substantial decrease in relative rates of fracture. The second study compared romosozumab and alendronate, there were reduced fractures in the romosozumab group.
The next question he addressed was how long should you treat for? Christian points out that the frequency of side effects is low but the patient perception of the frequency of side effects is very high. Studies suggest that the incidence of ONJ is very low at 1-5/10,000 year treatment with anti-resorptive treatment.
Atypical fractures, the risk increases with time, and decreases on discontinuation of treatment. A recent paper quantified the risk after 2 years of treatment is around 2/100,000 cases per year, and after 8 years it rises to 78/100,000 cases per year.
Drug holidays and discontinuing therapy is a hot topic but the amount of evidence is not as great as with the effect of our drugs. One can try to treat to target of T score of -2.5 for example and then discontinue but this is pretty arbitrary target. He did make the point that one needs to be careful in discontinuing some agents, for example denosumab, after discontinuing this it is good to use an anti-resorptive agent to stop the increase in bone resorption.
So, there is an increasing amount of data on the effect of therapeutics but now there are emerging studies on treatment strategies on osteoporosis which will likely guide practice in the future.