Osteoporosis Flashcards
Antiresporptive therapies
Raloxifene
Oral BP
Zoledronic acid
Denosumab
Anabolic therapies
Teriparatide
Abaloparatide
Romosozumab (mixed)
Limitations of long term individual therapy
Wanting efficacy
Greater risk of serious SE
Effects of bone density in BP use >5yr
FLEX study
Continued increase in spine density gains
No improvement in FN density
(Increase d SE risk)
Denosumab efficacy >5yr
Continued improvement in BMD
(10yr safety data but limited sample size)
Consequences of discontinuing Denosumab
Rapid loss of bone density back to baseline within a year for many
Vertebral fracture rate same as untreated (often multiple fx)
Discontinuation of anabolic therapy
Bone starts slowly loosing gains but continued fracture risk
Effect on BMD when switching from PTH analog to BP
BMD increases as quickly or more quickly than de novo BP therapy
Effect on BMD when switching from PTH analog to Denosumab
Quicker increase in BMD than de novo Denosumab
Effect on BMD when switching from BP to anabolic therapy
Blunting if efficacy
Effect on BMD when switching from Denosumab to anabolic therapy
Loss of gain over 1st year then increase
Rebound increase in resorption by evidence of increased osteocalcin and c-telopeptide
DON’T DO THIS
Romosozumab MOA
Antagonist to sclerostin (growth factor that increases osteoblast function)
3mo potent anabolic effect then 9mo antiresorptive effect
Pathophysiology of osteoporosis
Imbalance in bone due to increased osteoclast function and/or decreased osteoblast function
Effect on BMD when switching from Romosozumab to Denosumab or BP
Continued benefits to BMD
Effect on BMD when switching from BP or Denosumab to Romosozumab
Blunting of Romosozumab efficacy with both treatments but greater in Denosumab
Effect on BMD and bone turnover when switching from Denosumab to BP
BMD maintained
Denosumab resorption rebound avoided
(Slender ate more effective than zolendronic acid)
Compare transition from Denosumab to alrndronate or raloxifene
Alendronate is more effective that raloxifene at preserving BMD but raloxifene is still going to limit post Denosumab bone loss
Combination therapy
PTH analog and BP : no added benefit
PTH analog and Denosumab: additive benefit (DATA study based on 9mo high dose teriparatide and 12mo standard Denosumab)
Duration of therapy: oral BP
5yr
Duration of therapy: IV BP
3yr
Duration of therapy: Denosumab
5-10yr
Duration of therapy: PTH analogs
2yr
Duration of therapy: Romosozumab
1year
Duration of therapy: raloxifene
No maximum
