Combination and sequential therapy for the treatment of Osteoporosis

Published on January 19, 2015   22 min
0:00
Hello, my name is Felicia Cosman. I'm an endocrinologist and medical director of the Clinical Research Center at Helen Hayes Hospital, and professor of medicine at Columbia University College of Physicians and Surgeons. Today, I'll be talking about the role of combination anabolic and antiresorptive therapy for the treatment of severe osteoporosis Here are my disclosures.
0:28
The majority of pharmacologic agents for osteoporosis are antiresorptive medications, which act primarily by inhibiting osteoclast number, lifespan, and/or activity, and thereby reducing the rate of bone resorption. Antiresorptive medications include all of these listed here. But the most commonly used for the treatment of osteoporosis, at least in adults above age 65, are the bisphosphonates, including oral alendronate, risedronate, and ibandronate, the intravenous bisphosphonate zoledronic acid, and the RANK ligand inhibitor denosumab. There is only one class of anabolic therapy with two agents that are both parathyroid hormone analogues, the intact PTH 1-84 molecule and the amino terminal PTH peptide teriparatide. With anabolic agents, the mechanism of action is a direct stimulation of osteoblast number, activation, and/or function leading to a rapid increase in bone formation and a subsequent stimulation of osteoclast activity and overall bone remodeling with a persistent net increment in bone formation.
1:43
At the current time, we do not have any guidelines, or really even any consensus of opinion, about which patients should receive anabolic medication as first line treatment instead of antiresorptive medication. Certainly I would argue that for the highest risk patients, such as those with recent fractures within the preceding year, or those with a history of multiple prior fractures, these patients would be appropriate candidates in whom to use anabolic medication, and perhaps, as I hope to illustrate in this talk today, maybe even combination therapy for these very high risk individuals. Unfortunately, many doctors are not choosing to use anabolic therapy until patients have already had a sub-optimal response to their first osteoporosis medication and antiresorptive treatment. This is sometimes mandated by payer limitations, but also is often a lack of understanding, that we do see a different response than to anabolic therapy in patients who have already been treated with potent antiresorptive medication. And then in fact, in this group of patients, we really have no fracture efficacy data at all.
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Combination and sequential therapy for the treatment of Osteoporosis

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