Anabolic, antiresorptive agents the ‘ideal one-two punch’ for osteoporosis

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DESTIN, Fla. — Patients with osteoporosis may benefit from treatment initiation with an anabolic agent followed by an antiresorptive agent, according to a speaker at the Congress of Clinical Rheumatology East.

“Osteoporosis has been called a silent disease,” E. Michael Lewiecki, MD, clinical professor of medicine at the University of New Mexico Health Sciences Center, and director of the New Mexico Clinical Research and Osteoporosis Center, told attendees. “It can become very noisy in an instant when somebody has a fracture.”

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“We can treat osteoporosis but we can’t cure it,” E. Michael Lewiecki, MD, told attendees. “Any treatment is better than none.” Image: Jason Laday | Healio

Quieting that noise is often a matter of making the right therapeutic choice at the right time, according to Lewiecki.

That begins with assessing fracture risk, which will guide the initial treatment option.

“The greater the fracture risk the more aggressive the treatment,” Lewiecki said. “If they are at very high risk, you might consider anabolic therapy.”

In addition to anabolic therapies, antiresorptive agents are also used to treat osteoporosis. “We divide them into two categories — those that inhibit bone resorption or bone remodeling, and those that stimulate bone formation,” Lewiecki said.

Antiresorptive medications include alendronate (Fosamax, Merck Sharp & Dohme), risedronate (Actonel, Procter & Gamble), ibandronate (Boniva, McKesson), zoledronic acid (Reclast, Novartis) and denosumab (Prolia, Amgen).

Currently, three anabolic therapies — teriparatide (Forteo, Eli Lilly & Co.), abaloparatide (Tymlos, Radius) and romosozumab (Evenity, Amgen) — are commonly used, according to Lewiecki.

“Anabolic agents are the big gorillas for osteoporosis treatment,” he said. “They not only increase bone density but they improve bone structure.”

Importantly, romosozumab is unique because it has the dual effect of increasing bone formation while decreasing bone resorption, according to Lewiecki.

Despite an emerging body of head-to-head data showing the superiority of anabolic agents over antiresorptive agents, Lewiecki stressed that both classes have a place in osteoporosis treatment.

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E. Michael Lewiecki, MD,

“The ideal one-two punch for someone with osteoporosis is to begin therapy with an anabolic agent and follow it up with an antiresorptive agent,” he said.

However, many insurance carriers suggest initiating an antiresorptive agent first due to cost. Lewiecki described this as potentially “counterproductive,” given that bone density may steadily decrease with the antiresorptive agent. Moreover, anabolic therapies can be less effective when administered after antiresorptive agents have been used.

“If the health plan asks why you want to use such a hugely expensive drug, you can tell them because they are better,” Lewiecki said.

A final key consideration in sequencing osteoporosis medications, at the moment, pertains to so-called “drug holidays” or treatment discontinuation, he added.

When bisphosphonate medications are discontinued, small decreases in bone density are reported, according to Lewiecki.

“But after stopping anabolic agents or denosumab, the decreases in bone density are very large,” he said.

Clinicians are encouraged to consult the European Calcified Tissue Society (ECTS) guidelines for information regarding treatment discontinuation in osteoporosis.

Whatever treatment choices are made, Lewiecki encouraged the management of expectations.

“We can treat osteoporosis but we can’t cure it,” he said. “Any treatment is better than none. Some are better than others.”

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