Osteoporosis Treatment Overview. Colton Larson RFUMS October 26, 2018

Transcription

1 Osteoporosis Treatment Overview Colton Larson RFUMS October 26, 2018

2 Burden of Disease Most common bone disease 9.9 million Americans million Americans have low bone mineral density (BMD) Stealthy onset a hidden disease Very serious outcomes in terms of morbidity and mortality Wright NC, Looker AC, Saag KG, et al. J Bone Miner Res. 2014;29(11): Office of the Surgeon General (US)

3 HEDIS 2016 Excludes: Fractures of the fingers, toes, face, and skull If BMD tested during the preceding 24 months Osteoporosis therapy preceding 12 months Osteoporosis medication preceding 12 months HEDIS 2016: Osteoporosis Therapies Bisphosphonates Other Agents Alendronate Alendronate-cholecalciferol Ibandronate Risedronate Zoledronic acid Calcitonin Denosumab Raloxifene Teriparatide National Committee for Quality Assurance. August 30 th, 2018.

4 HEDIS BMD Testing Rates HMO PPO National Committee for Quality Assurance. August 30 th, 2018.

5 HEDIS Drug Prescribed HMO PPO National Committee for Quality Assurance. August 30 th, 2018.

6 Diagnosis Fragile fracture is one that shouldn t occur If no fragility fracture use BMD score BMD T-score -2.5 osteoporosis BMD T-score -2.5 to -1 osteopenia Exclude hyperparathyroidism and osteomalacia Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

7 FRAX Uses clinical risk factors & femoral neck BMD Predicts 10 year risk Lower sensitivity for 50 to 54 years Poor predictor for men Postmenopausal women 50 to 64 years Readily available online Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

8 Risk Factors Stereotypical : 65 y.o. underweight Caucasian woman, who smokes 1 ppd, drinks 3 glasses of white wine a day with a history of falling at home which has lead to her adopting a very sedentary lifestyle. Medications: PPI, anticoagulants, barbiturates and chemotherapy Hypogonadal states Rheumatologic and autoimmune diseases Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

9 Risk factors for falls History of falling Muscle weakness and gate disturbance Medications sedatives, opiates, antihypertensives Balance impairment stroke, joint problems Visual deficits Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

10 Non-Pharmacological Interventions and Universal Recommendations 1200 mg calcium/day International units vitamin D/day Weight bearing exercise strongly recommended Fall prevention Smoking cessation Stop or reduce alcohol drinking Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

11 Screening Complete baseline evaluation and risk assessment before starting a medication DXA BMD testing should be done in women 65 years of age Yearly height recorded Serum 25(OH)D level ~ 30 ng/ml (75 nmol/l) Rule out secondary causes US Preventive Services Task Force, Curry SJ, Krist AH, et al. JAMA. 2018;319(24):

12 When to treat Postmenopausal women and men > 50 years old Hip or vertebral fracture T-score -2.5 at femoral neck, total hip or lumbar spine T-score at femoral neck or lumbar spine with a 3% 10 year probability of hip fracture or a 20% 10 year probability of a major osteoporotic fracture Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

13 ACP & NOF Bisphosphonates and denosumab first line to prevent fractures Hormone therapy and raloxifene not generally recommended Bisphosphonates for 3 to 5 years and reassess Severe osteoporosis may start with anabolic therapy Qaseem A, Forciea MA, McLean RM, Denberg TD. Ann Intern Med. 2017;166(11): Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

14 Bisphosphonates First line treatment for 3 to 5 years Osteonecrosis of jaw and atypical femur fractures increase after 5 years Re-assess after 3 to 5 years BMD Height measurement vertebral imaging Clinical history Risk moderate now then discontinue bisphosphonates Risk high then continue bisphosphonates Alternate treatment considered now too Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10):

15 Bisphosphonates Bisphosphonates work by binding locally at the bone, where they inhibit osteoclast activity Agents of this class have an extended terminal half life They have FDA approvals for osteoporosis and prophylaxis Micromedex 2.0 (Healthcare Series), (electronic version). Available at:

16 Bisphosphonates Use of oral bisphosphonates is contraindicated with GI complications Contraindicated in patients who cannot adhere to administration protocol Contraindicated with uncorrected hypocalcemia Use is contraindicated with a creatinine clearance ml/min Ibandronate can be given IM Zoledronic acid is given IV Micromedex 2.0 (Healthcare Series), (electronic version). Available at:

17 Bisphosphonates Good Rx Fair Price Fosamax (alendronate) $10 Boniva (ibandronate) $37 Actonel (risedronate) $64 Atelvia (risedronate dr) $74 Etidronate $371 Binosto (aldronate) $210 Reclast (zoledronic acid) $1,082 Goodrx.

18 Denosumab (Prolia ) Binds to RANKL, which leads to the inhibition of formation, function and survival of osteoclasts Given subcutaneously every 6 months Contraindicated in uncorrected hypocalcemia or pregnancy Good Rx price $1,180 1 syringe Micromedex 2.0 (Healthcare Series), (electronic version). Available at: Goodrx.

19 Human Parathyroid Hormone Analogues Parathyroid hormone is the primary regulator of calcium and phosphorus in the bones and kidneys Agents in this class have a black box warning for osteosarcoma Use is cautioned in individuals with current or recent urolithiasis Micromedex 2.0 (Healthcare Series), (electronic version). Available at:

20 Parathyroid Hormones Good Rx Fair Price Forteo (teriparatide) $3,268 Tymlos (abaloparatide) $1,829 Goodrx.

21 Raloxifene (Evista ) Raloxifene is a selective estrogen receptor modulator that decreases bone reabsorption and increases bone mineral density Reduces vertebral fractures Use is contraindicated with venous thromboembolism and pregnancy Use is cautioned with renal or hepatic impairment Not typically a preferred use medication Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10): Micromedex 2.0 (Healthcare Series), (electronic version). Available at:

22 Calcitonin (Miacalcin, Fortical ) Functions as calcitonin Reduces osteoclast activity in bone Calcitonin reduces vertebral fracture risk May increase risk of malignancy Not frequently used Not FDA approved for osteoporosis Cosman F, de Beur SJ, LeBoff MS, et al. Osteoporos Int. 2014;25(10): Micromedex 2.0 (Healthcare Series), (electronic version). Available at:

23 Conclusions Osteoporosis is under diagnosed and under treated Many medications exist with no clear best drug Predicting treatment need is imperfect Everyone at risk should be urged to understand and adopt non pharmacological approaches More research needed Head to head Longer than 5 years

24 Bibliography 1. Miller PD, Hattersley G, Riis BJ, et al. Effect of abaloparatide vs placebo on new vertebral fractures in postmenopausal women with osteoporosis: A randomized clinical trial. JAMA. 2016;316(7): doi: /jama [doi]. 2. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the united states based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11): doi: /jbmr.2269 [doi]. 3. National Committee for Quality Assurance. Osteoporosis Testing and Management in Older Women. August 30 th, Accessed December 12 th, Office of the Surgeon General (US). Bone Health and Osteoporosis Accesed 12/3/ Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10): doi: /s [doi]. 6. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: US preventive services task force recommendation statement. JAMA. 2018;319(24): doi: /jama [doi]. 7. Qaseem A, Forciea MA, McLean RM, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update from the american college of physicians. Ann Intern Med. 2017;166(11): doi: /M [doi]. 8. Rosen HN, Drezner MK. Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women. In: Ted Post, ed. UptoDate. Waltham, MA: UptoDate; Accessed October 24 th, US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: US preventive services task force recommendation statement. JAMA. 2018;319(24): doi: /jama [doi]. 10. Micromedex 2.0 (Healthcare Series), (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: Accessed: October 10 nth, Goodrx. December 16 th, 2018