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Treating osteoporosis to prevent fractures: current concepts and future developments

Journal article
Authors Mattias Lorentzon
Published in Journal of Internal Medicine
Volume 285
Issue 4
Pages 381-394
ISSN 0954-6820
Publication year 2019
Published at Institute of Medicine
Pages 381-394
Language en
Links dx.doi.org/10.1111/joim.12873
Keywords anabolic treatment, antiresorptive treatment, bone mineral density, FRAX, osteoporosis, romosozumab, bone-mineral density, postmenopausal women, vertebral fractures, parathyroid-hormone, zoledronic acid, hip fracture, teriparatide, treatment, older women, osteoprotegerin ligand, antiresorptive therapy, General & Internal Medicine, mpster dw, 1993, endocrine reviews, v14, p690
Subject categories Geriatrics

Abstract

Antiresorptive drugs, such as the bisphosphonates and the RANKL inhibitor denosumab, are currently the most widely used osteoporosis medications. These drugs increase bone mineral density (BMD) and reduce the risk of vertebral (by 40-70%), nonvertebral (by 25-40%) and hip fractures (by 40-53%) in postmenopausal women with osteoporosis. Due to the risk of rare side-effects, the use of bisphosphonates has been limited to up to 10years with oral bisphosphonates and 6years with intravenous zoledronic acid. Despite their well-proven efficacy and safety, few women at high risk of fracture are started on treatment. Case finding strategies, such as fracture risk-based screening in primary care using the fracture risk assessment tool (FRAX) and Fracture Liaison Services, have proved effective in increasing treatment rates and reducing fracture rates. Recently, anabolic therapy with teriparatide was demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture. Treatment with the sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis. For patients with severe osteoporosis and high fracture risk, bisphosphonates alone are unlikely to be able to provide long-term protection against fracture and restore BMD. For those patients, sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, will likely provide better long-term fracture prevention and should be the golden standard of future osteoporosis treatment.

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