Osteoporosis: how long to treat?

Published on January 19, 2015   49 min
0:00
Hello, my name is Robert Adler, and I'm from the Veterans Hospital in Richmond, Virginia. I teach at Virginia Commonwealth University where I'm in the Department of Medicine as well as Epidemiology and Community Health. My topic today is how long to treat osteoporosis. And I thank Professor Juliet Compston for the opportunity to discuss this most challenging subject.
0:30
Here are my disclosures on the next slide.
0:34
And on the next slide, the topics that I will cover today. First of all, I'm going to talk about why this is such an important subject because fractures are really quite common. And then I'll go over the treatments that we have emphasizing bisphosphonates because they've been the mainstay of our osteoporosis treatment. I will review the few long-term studies we have, and then talk about the importance of individualizing assessment and treatment in your patients.
1:06
In the next slide, I show just how common osteoporotic fractures are. This is data from the States, but it's applicable to many other countries. And then in a given year, a woman has a much greater chance of having an osteoporotic fracture than developing a new onset heart disease or breast cancer.
1:30
And even in men, as shown in the next slide, osteoporotic fracture is more common than many other disorders that are of more general concern, such as prostate cancer or stroke.
1:46
And indeed, in the States, there are over two million fractures a year. Two million osteoporotic fractures. I'm not talking about traumatic crack. And if you look at our overall results of treatment, we can prevent about half of those fractures if we could identify those patients at risk and treat them, because that's what our treatment can do.
2:12
So at age 50 a woman has about a 1/3 chance of having an osteoporotic fracture before she dies. And for a man, that risk is about 1/5, so that's a lot of people. And indeed, if you count up both Europe and the Americas, there are about four and a half million osteoporotic fractures each year. And as our population ages, there are going to be more, so this is a large and growing problem.
2:46
Here in the next slide I list some of the causes of secondary osteoporosis. And there's a reason for my showing this now, but here are just some of the specific disorders that are associated with osteoporosis- glucocorticoid-induced osteoporosis being the most common and actually the most devastating. But hyperthyroidism, hypogonadism, malabsorption, alcohol excess, increased urinary calcium, hyperparathyroidism, hyperprolactinemia, and a host of medications including aromatase inhibitors, and tamoxifen in younger women, and androgen deprivation therapy in men. All of these are secondary causes of osteoporosis. And the reason I put this up, as shown in the next slide, is it
3:32
many times the treatment of the underlying disorder may be sufficient to reduce fracture risk. And the patient will not need other osteoporosis therapy. And in some cases, the treatment will be lifetime. And so there won't be a lot of discussion about how long to treat these patients. On the other hand, some of the patients will not be adherent to their therapy. And as they age they will be subjected to the same kinds of problems that all of us have as we age, that is "garden variety" primary osteoporosis that occurs with aging, so that the treatment for the secondary osteoporosis may have been sufficient early on. With time, they may need something more. So you can't forget about other treatments in such patients.
4:23
In the next slide I list all the different kinds of treatment of osteoporosis. And I put bisphosphonates in a different color because those are the most common kinds of treatments we use today. And I will speak to all the others.
4:41
In the next slide I list all the FDA (US Food and Drug Administration) approved indications for bisphosphonates. And the four that are approved for osteoporisis in the States are alendronate, risedronate, ibandronate, and zoledronic acid.
4:58
And in the next slide, I list the medications that are approved for osteoporosis by the European Medicines Agency, and include the same bisphosphonates that I've already mentioned, however including bazedoxifene in addition to raloxifene as a selective estrogen receptor modulator. Denosumab, teriparatide. Parathyroid hormone 1-84 was approved but apparently has been withdrawn, and strontium ranelate is also available.
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Osteoporosis: how long to treat?

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