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Treatment Choices

CE / CME

How I Choose Among Osteoporosis Treatments

Physicians: Maximum of 0.25 AMA PRA Category 1 Credit™

Nurses: 0.25 Nursing contact hour

Released: May 25, 2021

Expiration: May 24, 2022

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The goal of reducing fracture risk raised some interesting questions on osteoporosis treatments and osteoporosis risks in our recent webinar. In this commentary, I answer questions posed during the live event.

Estrogen was once a great osteoporosis prevention drug. Is it no longer commonly used?
Many observational studies, as well as small, randomized, placebo-controlled clinical trials, have shown that estrogen prevents bone loss in postmenopausal women. In addition, 2 very large randomized clinical trials, the Women’s Health Initiative and the HERS trial, evaluated the effect of estrogen replacement therapy on a number of health-related outcomes, including cardiovascular disease, cerebrovascular events, and osteoporosis. In these studies, estrogen did preserve bone mass and reduce the risk of hip fractures.

However, these studies also showed that the combination of estrogen with progesterone increased the risk of breast cancer and cardiovascular events, including cerebrovascular events. Therefore, the recommendations are that although estrogen can prevent bone loss and reduce incident hip fractures, the risks of estrogen replacement outweigh the benefits.

For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-to-risk ratio of hormone therapy is most favorable for treatment of bothersome vasomotor symptoms and for treating those at elevated risk for bone loss or fracture.

For women who initiate hormone therapy more than 10 or 20 years from menopause onset or are 60 years of age or older, the benefit-to-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia.

In many cases, estrogen has been replaced by raloxifene, a selective estrogen receptor modulator, which has estrogen-like effects on the bone and antiestrogen effects on the breast and uterus. It is effective in preventing incident vertebral fractures and increasing lumbar spine and hip bone mass, and it reduces the risk of incident breast cancer. However, the antiestrogen effects increase the risk of hot flashes, blood clots, and pulmonary emboli.

How do you choose among the anabolic agents?
There are currently 2 general groups of anabolic agents: the PTH compounds (the PTH 1-34 and PTHrP analogs teriparatide and abaloparatide) and an anabolic/antiresorptive agent (romosozumab, an antibody to sclerostin).  

Although both groups of anabolic agents can significantly increase bone mass at the lumbar spine, studies of romosozumab compared with teriparatide found greater increases in bone mineral density at the hip and finite element modeling for bone strength during a 12-month treatment period.

The difference in changes in hip bone mass between romosozumab and teriparatide is that, whereas both agents are anabolic, romosozumab also has an antiresorptive effect. The combination of these effects results in an increase in hip bone mass.

Therefore, if a patient has osteoporosis at both the hip and spine, I am likely to choose romosozumab as the first treatment.

Is there a risk of fracture with inhaled steroids?
Glucocorticoids or steroids are the most common cause of medication-induced bone loss. Patients who are treated with oral prednisone doses >7.5 mg/day can rapidly lose bone within 6 months. Patients receiving oral steroid medications need to be treated with bone-active agents to prevent the loss of bone and decrease the risk of fractures.

Inhaled steroids—when used for short periods (less than 1-2 months) or not too frequently (not more than twice daily)—generally do not cause bone loss or increase bone fragility. However, if inhaled steroids are used every day for months or years or if they are used more frequently each day, they can result in loss of bone mass and fractures.

This is an important message for patients to understand: Continual use of inhaled steroids and use multiple times per day can reduce bone mass and strength.

The bottom line is that inhaled steroids that are generally prescribed for breathing problems do not affect bone if used as prescribed and infrequently. But if patients need continued treatment with inhaled steroids over a number of months, then treatments to preserve bone mass and strength should be discussed with them.

Your Thoughts?
What questions do you have about treating osteoporosis in your patients? Please answer the poll and post your thoughts and questions in the discussion box.

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