Osteoporosis: Using Novel Therapies in Practice

Peter L. Salgo, MD: Let’s examine the way the newer agents are authorized. We’re doing a little economics lesson here. Are the payers requiring step therapy? And in this disease, what is step therapy?

Andrea J. Singer, MD, FACP, CCD: So the simple answer is, it depends. The reason I say that is because there is a lot of variation, both geographically, even within the same payer, and then by payers in terms of what they require. And there’s a difference between Medicare and commercial insurance, and obviously we’re talking largely about a Medicare-based population because we’re talking about an older population. But we see lots of fractures in people between the ages of 50 and 64, so commercial insurance comes into it as well. Sometimes step therapy is required, or they will at least inquire about whether the patient been tried on a bisphosphonate, an oral bisphosphonate. Have they tried or been intolerant to or failed a couple? Have they tried other agents before you sort of move on? That’s not across the board. And again, as a provider, I think if you can make a good argument that clinically this is why I feel we need to start here, sometimes that works [and] other times it does not.

Peter L. Salgo, MD: Do they need prior authorization?

Andrea J. Singer, MD, FACP, CCD: Some of them. Again, with Medicare and those drugs that fall under Part B—and denosumab and romosozumab fall under Part B, as opposed to Part D—then you’re talking about medical benefits versus pharmacy benefits. Their prior authorization tends to be less of an issue in the nonmanaged Medicare group, as compared with drugs, or some of the other anabolics, and all that, which fall under Part D.

Peter L. Salgo, MD: I’ll tell you what this sounds like to me. Back when we first introduced the statins, there were no generics. They were very expensive. And I heard from third-party payers, “It’s too much money. We’re not going to leave it on the formulary.” And I asked, “Well, what about all these folks who have myocardial infarctions a year from now, who might not have if their serum lipids had been controlled?” And they said, “Not my problem. I’ve got to make my quarter.” Does this sound to you like the same argument?

Thomas P. Olenginski, MD, FACP, CCD: I mean, in a way. I think there’s another segment of the high-risk population for whom the attractiveness of how these drugs work is going to be a harder sell. And that’s going to be someone, let’s say younger but at higher risk because of really bad scores, for whom we really want to prevent the event. That’s going to be a different challenge and hurdle. I proactively try to communicate to a medical director this goal-directed, individualized, treat-to-target therapy that I hope continues, at least to make it understandable.

Peter L. Salgo, MD: Going forward into the future, do you see a complete shift toward these—I’ll call them biologicals for lack of a better phrase—away from the bisphosphonates, away from the standard therapies? Is this where we’re all going, given time, given price decreases over time?

Thomas P. Olenginski, MD, FACP, CCD: I don’t think the bisphosphonates. I think the bisphosphonates are here to stay. The 1 advantage that Dr. Singer pointed out is that once you get to a place that you like, there’s persistence of effect. So 1 of the patients I’m talking about, younger but higher risk, if you use something and get them somewhere, then maybe you can give them a bisphosphonate and watch them.

Peter L. Salgo, MD: Again, what I hear is that it depends. It depends. A lot of drugs, some drugs are good, some of these new drugs are really good.

Claire Gill: They are. And I think, again from a patient-efficacy perspective, part of what we spend a lot of time advocating for is that, again, given the unique circumstances of osteoporosis patients and the chronicity of the disease—and as you’ve heard the doctors explain how it can vary so differently from patient to patient—having access to all the treatments available for osteoporosis is essential.

Peter L. Salgo, MD: This has been great, but now it’s time to wrap things up. Why don’t we go around and ask each of you for 30 seconds or your final crystalline thought. Is there something you’d like to share with your viewers? Why don’t we start here?

Claire Gill: I think from our perspective, again, it’s appreciating what the doctors are doing every day for their patients and just, again, looking at those at highest risk for fracture, those who have had a hip fracture, those who have had any type of fracture, to consider getting them a DEXA [dual-energy x-ray absorptiometry] scan.

Peter L. Salgo, MD: Tom?

Thomas P. Olenginski, MD, FACP, CCD: Well, first of all, thank you for inviting me. I would say for anyone who’s concerned about their bone health, ask your doctor what you should do. For patients who sustain a fracture, my hope over the next decade is that the standard of care will always be a risk-assessment evaluation and treatment if appropriate.

Peter L. Salgo, MD: Andrea?

Andrea J. Singer, MD, FACP, CCD: If you are someone or have a patient who’s 50 years of age or older and has had a fracture, that patient needs to be evaluated for an underlying bone condition. And we need to keep in mind that once we do diagnose osteoporosis, this is a chronic disease, so we need to take care of our patients and follow them over a lifetime.

Peter L. Salgo, MD: I want to thank all of you for being here. This has been kind of an eye-opening discussion for me, in terms of risk and some new drugs that are out there. I know new drugs are coming because there [are] new drugs everywhere. But thank you all. It’s been just terrific. I want to thank you, too, for watching. It’s nice of you to be with us. I hope you found this Peer Exchange discussion to be useful and informative. I’m Dr. Peter Salgo, and I’ll see you next time.