Osteoporosis: Pharmacologic Therapy

Peter L. Salgo, MD: Let’s talk about some treatment options here. We talked about non-pharmacologic treatment. What about the basics that all primary care physicians know of, that are relatively straightforward to initiate? What are the basic treatments for osteoporosis?

Andrea J. Singer, MD, FACP, CCD: For most primary care physicians, if you ask them, the first class of medication that they would mention would be the bisphosphonates. We have 2 major umbrellas of medications. The antiresorptive are those medications that slow bone breakdown. The bisphosphonates are the most well-known in that category. And then we have another umbrella, the anabolics, or bone-building medications, which by and large, are probably not as readily prescribed by primary care physicians.

Peter L. Salgo, MD: Should they be?

Andrea J. Singer, MD, FACP, CCD: They have an absolute role in the management of osteoporosis. Should they be prescribed by primary care physicians? I think it depends on their comfort level. The recognition that there are other options and that perhaps something else is more appropriate, and, “I’m not comfortable prescribing. That’s when I should refer to a specialist,” I think is as important as being able to write the prescription.

Peter L. Salgo, MD: Where do calcium and vitamin D fit in with all of this?

Andrea J. Singer, MD, FACP, CCD: They are part of the management plan regardless of what we do, or what one is prescribing.

Peter L. Salgo, MD: Either with anabolics or with….

Andrea J. Singer, MD, FACP, CCD: Yes. All of the clinical trials for osteoporosis medicines have been done when patients have been supplemented with calcium and vitamin D. So some baseline level is important as part of the treatment plan.

Peter L. Salgo, MD: And do your treatment approaches, this basic pharmacologic approach, in the presence one would hope of good exercise and whatever else, change based on age and fracture risk?

Thomas P. Olenginski, MD, FACP, CCD: Yes. As Dr Singer nicely pointed out, bisphosphonates are the base, so it’s the standard of care. So for patients who are older, with risks, and a fracture, that’s much more significant than someone 10 or 20 years younger without that. We talk about risk. In somebody who has been treated and has fractures, maybe is on prednisone, steroid medicine, and they’ve had problems or their T-scores are in a more worrisome range, that’s typically the place for some of the other things that we’re going to be talking about. What is hopefully going to emerge over the next decade, and we talk about what is not in everyone’s language in day-to-day care, is kind of an individualized goal-directed treatment approach, or how to use the drugs in sequence. And it’s these newer drugs that have different mechanisms of action that probably can afford that type of patient a better outcome.

Peter L. Salgo, MD: Let’s role-play for a minute. I’m going to come to see you. I’m 65 years old. I’ve never been tested. I’m a little worried. My mom had a fracture when she was 85. I’m female, if you will. What is your cocktail? How do you start? Just make believe you’re taking care of a patient for the first time.

Andrea J. Singer, MD, FACP, CCD: If you’ve never been evaluated, never had a bone density test, given your age and risk from a family perspective, we should get a bone density test.

Peter L. Salgo, MD: OK. We get that. It comes back. It’s worrisome. Now, I’ve never been treated.

Andrea J. Singer, MD, FACP, CCD: And you’ve never had a fracture.

Peter L. Salgo, MD: Never had a fracture. How do you start treating me?

Andrea J. Singer, MD, FACP, CCD: Well, I look at the rest of your medical history. For argument’s sake, there aren’t really any complicating factors. We would talk about the different options based on your risk level. The fact that you’re 65 or above puts you at high risk. The older we get, the greater the risk for fracture. Let’s say your bone density is really quite low and worrisome. Then we have to talk about the approach in terms of whether we want to start with an agent that is going to sort of build bone as opposed to one that maintains. A couple of comments there, or corollaries in terms of the way I would approach this: I have a very open discussion with patients in terms of laying out the options that are there, talking about benefits versus risks, and importantly, the risk of not doing anything. Because that’s the piece that we often forget to balance.

The other thing is, we need to make sure that people understand osteoporosis is a chronic disease. Just like diabetes, just like heart disease, I can treat this and control it and reduce risk. I can’t cure it. So this is going to be something that we’re going to have to manage for the rest of your life. Management can look like different things, in terms of what drug we start with and what we then switch to. But it’s not as though you treat for 2 years and you’re better, and I don’t need to see you anymore.

Peter L. Salgo, MD: No, it’s not all gone.

Andrea J. Singer, MD, FACP, CCD: Right. It’s not all gone.

Peter L. Salgo, MD: Now, you monitor me. What would cause you to add other agents to the regimen we started with? What would make you switch?

Andrea J. Singer, MD, FACP, CCD: It’s not always or often an add. It might be a switch. That would be something that we would deem a true treatment failure. So what’s treatment failure? That sounds like an easy question, but it isn’t. It might be somebody who has lost bone density, a significant amount of bone density, more than the inherent difference you would see in the machine. But it’s a true bone density loss. It might be somebody, if you’re following bone turnover markers, who’s not responding the way one would expect. This is all assuming that you’re taking the drug, taking it correctly, and nothing else has happened in the interim. What about the patient who’s fractured? None of the medications we have available reduce fractures by 100%, so a single fracture doesn’t necessarily mean treatment failure in the individual patient, although we don’t like to see that happen. But if you’ve had more than 1 fracture, then I need to think about why this medication is not working.