Spanish consensus on treat to target for osteoporosis

Abstract

SummaryTo reach a Spanish expert consensus on a treat-to-target strategy in osteoporosis, a Delphi Consensus Study has been developed. Most of the experts (59.8%) were rheumatologist with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items. Therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been defined.IntroductionThe paper aims to achieve a Spanish expert consensus on a treat-to-target (T2T) strategy in osteoporosis.MethodsA scientific committee led the project and was involved in expert panel identification and Delphi questionnaire development. Two Delphi rounds were completed. The first-round questionnaire included 24 items and assessed, using a seven-point Likert scale, the experts’ wish (W) and prognosis (P) in 5 years for each topic (applicability, therapeutic objectives, patient follow-up, and possible treatment to be prescribed). Items for which there was no consensus in the first round were included in the second round. Consensus was defined as ≥75% agreement (somewhat/mostly/entirely agree) or disagreement (somewhat/mostly/entirely disagree) responses.ResultsOf the experts, 112 and 106 completed the first and second rounds, respectively. 59.8% were rheumatologists with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items, and was established regarding the utility of a T2T strategy to define therapeutic objectives, optimal follow-up, and therapeutic algorithm. Participants agreed on the utility of the bone mineral density (BMD) value (T-score >−2.5 SD for spine and >−2.5/−2.0 SD for femoral neck), lack of fractures, and fracture risk (FRAX) as therapeutic objectives. For measuring BMD changes, consensus was achieved on the suitability of hip and femoral neck locations. Experts agreed to consider treatment failure as when a significant BMD gain could not be achieved, or when a new fracture occurs within 2–3 years. There was consensus that all proposed therapies should achieve a therapeutic target through T2T strategy (treatments with the highest consensus scores were denosumab and teriparatide).ConclusionThe therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been established by a panel of experts. Some aspects nevertheless still require further analysis.

Is a treat-to-target strategy in osteoporosis applicable in clinical practice? Consensus among a panel of European experts

“…The results reported here are consistent with the outcomes of the Spanish Delphi panel and ASBMR-NOF working group [4,20]. Both groups concluded that a T2T approach is applicable in osteoporosis and set the therapeutic objectives as absence of new fractures, including those that do not present clinically, increase in BMD and reduction in FRAX risk score [4,20]. In order to integrate the occurrence of morphometric vertebral fractures into a T2T strategy, it will be necessary to improve diagnoses of these fractures in order to accurately assess progress towards the treatment goal.…”

“…The ethos of shared decisionmaking to ensure patients have an active role in treatment choice would remain the same, however [28], and would therefore not leave the patient at the mercy of the treating physician alone. The results reported here are consistent with the outcomes of the Spanish Delphi panel and ASBMR-NOF working group [4,20]. Both groups concluded that a T2T approach is applicable in osteoporosis and set the therapeutic objectives as absence of new fractures, including those that do not present clinically, increase in BMD and reduction in FRAX risk score [4,20].…”

“…A T2T strategy in osteoporosis could help to address the unmet needs in fracture management by identifying a suitable treatment target, individualizing the initial treatment choice and guiding shared decision-making. Given the low treatment adherence rates in osteoporosis [18,19], a T2T approach could increase patient engagement, improving adherence and therefore outcomes [17,20,21]. In 2018, a Spanish expert panel established the applicability of a T2T strategy for osteoporosis, including therapeutic objectives, patient follow-up, treatment failure criteria and appropriate treatment use [20].…”

“…Given the low treatment adherence rates in osteoporosis [18,19], a T2T approach could increase patient engagement, improving adherence and therefore outcomes [17,20,21]. In 2018, a Spanish expert panel established the applicability of a T2T strategy for osteoporosis, including therapeutic objectives, patient follow-up, treatment failure criteria and appropriate treatment use [20]. The American Society for Bone and Mineral Research-US National Osteoporosis Foundation (ASBMR-NOF) working group also supports a T2T approach in osteoporosis and recommends several principles to guide treatment selection and monitoring, for example, considering more potent initial treatment in patients with high risk of fracture [4].…”

“…The American Society for Bone and Mineral Research-US National Osteoporosis Foundation (ASBMR-NOF) working group also supports a T2T approach in osteoporosis and recommends several principles to guide treatment selection and monitoring, for example, considering more potent initial treatment in patients with high risk of fracture [4]. Clinical measures that could potentially be used as a target include bone mineral density (BMD) T-score, fracture risk assessment tool (FRAX) score, bone turnover markers (BTMs) and the absence of new fractures [4,15,20].…”