36 CLINICAL FOCUS
36 CLINICAL FOCUS
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A woman with severe osteoporosis presents with worsening back pain. She has been on an antiresorptive agent for two decades. Is it time to reassess therapy?
Dr Chitra Sivaramamoorthy GP in Sydney, NSW.
CATHY, a 71-year-old, presents with a six-month history of worsening back pain. She has a history of severe osteoporosis with vertebral fracture and has been on alendronate for 19 years.
Investigation
The assessing GP suspects a possible vertebral fracture and requests a CT scan. This confirms insufficiency fractures involving L1-L4, with loss of up to 80 % height. Bone mineral densitometry demonstrates a right femoral neck T-score of-2.1 and a radial T-score of-3.
Treatment
Cathy is referred to an endocrinologist, who ceases alendronate and starts teriparatide 20 µ g( SC injection) daily. Anticipated treatment duration is 18 months followed by resumption of antiresorptive therapy for consolidation with adequate calcium and vitamin D supplementation.
A follow-up bone densitometry assessment 12 months later indicates a decline in her BMD. At this point, the endocrinologist reintroduces alendronate 70mg weekly( concurrently with teriparatide). The plan is ultimately to switch both treatments over to denosumab 60mg( SC injection) six monthly for consolidation and long-term therapy.
Discussion
One in three women aged over 50 and one in five men over 50 will experience an osteoporotic fracture. 1 Lifestyle management is a key consideration. This includes adequate calcium and vitamin D intake; avoidance of smoking and excess alcohol; participation in weight-bearing and resistance-training exercise; and falls prevention. 2
Pharmacological options should be considered in those at high risk of minimal trauma fracture, such as those with proven osteoporosis, minimal trauma fracture and women with osteopenia who are ≥10 years postmenopausal. 3
Antiresorptive drug options slow osteoclastic activity, thereby reducing bone breakdown. These include bisphosphonates, denosumab and, in postmenopausal women, oestrogen therapy, raloxifene or tibolone. Osteoanabolic agents stimulate osteoblasts to build new bone. These agents include teriparatide and romosozumab. Abaloparatide is another osteoanabolic agent( a human parathyroid hormone – related peptide analogue) that is currently only available overseas. 3
Both antiresorptive and osteoanabolic agents are effective for vertebral fracture risk reduction in older female populations. 4
Bisphosphonates are potent osteoclast inhibitors. They are first-line treatment for osteoporosis, with good-quality evidence of reduced fracture risk. 3 They are generally very safe. Appropriate measures must be taken to avoid gastrointestinal side effects with the use of oral bisphosphonates.
Medication-related osteonecrosis of the jaw is a rare adverse event, affecting 1-10 patients per 10,000 patients treated with oral agents and 1.7 per 10,000 in those receiving