Management of patients at very high risk of osteoporotic fractures through sequential treatments

Abstract

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment and a range of effective pharmacological agents. Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an “anabolic first” approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

“…Those patients at ‘very high risk’, defined as either above the upper assessment threshold on FRAX ® assessment [ 10 , 11 ], or those with low bone mineral density (BMD) with advanced age, frailty, glucocorticoids, very low T scores or increased falls risk [ 9 ] are considered for bone-forming therapies first-line if these are available [ 9 , 10 ].…”

Intervention thresholds and diagnostic thresholds in the management of osteoporosis

“…It is widely recognised that BMD alone for fracture risk assessment is less sensitive than risk assessment algorithms, such as FRAX® that incorporate risk indicators in addition to BMD [7]. It is certainly relevant to question the need for diagnostic criteria when the field is moving towards riskbased assessment and intervention, including adjustments to FRAX and guidance thresholds to distinguish high risk from very high risk to optimise the use of anabolic agents [8][9][10][11][12]. These developments will inevitably decrease the clinical utility of the T-score, but they will, however, take time to implement into routine clinical practice.…”

The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis

“…It is widely recognised that BMD alone for fracture risk assessment is less sensitive than risk assessment algorithms such as FRAX that incorporate risk indicators in addition to BMD. It is certainly relevant to question the need for diagnostic criteria when the field is moving towards riskbased assessment and intervention, including adjustments to FRAX and guidance thresholds to distinguish high risk from very high risk to optimise the use of anabolic agents [67,[88][89][90][91]. These developments will inevitably decrease the clinical utility of the T-score, but they will, however, take time to implement into routine clinical practice.…”