Optimizing Anabolic and Antiresorptive Treatment Transitions for Osteoporosis

Announcer:
This is On the Frontlines of Osteoporosis on ReachMD. On this episode, we’ll learn from Dr. Felicia Cosman about the various factors that can determine the optimal treatment sequencing approach for patients with osteoporosis. Dr. Cosman is a Professor of Medicine at Columbia University. Let’s hear from her now.

Dr. Cosman:
It’s important to consider how treatment sequencing impacts osteoporosis care in postmenopausal women, and I think one key message here is some women do want to stop denosumab. Maybe they’ve reached treatment goals. Maybe they have other comorbidities that have come up and necessitate stopping it. Maybe they’ve had an adverse event. And these patients need to be managed carefully, particularly if they’ve been on long-term denosumab, where we often recommend zoledronic acid at the time that the next denosumab dose is due—another dose six months later and a third dose six months after that—and that gets us through that very high-risk period. 

For people who have not been on prior osteoporosis medications who present as very high risk, the optimal approach is to treat with an anabolic agent first, followed by an antiresorptive, and this will produce the best and most rapid fracture risk reduction and the greatest improvement in bone density. For patients who’ve been on medications such as estrogens or raloxifene, probably there will be no negative impact on the effects of an anabolic agent making that transition, but for those who’ve been on bisphosphonates or denosumab, the impact of anabolic therapy is blunted to some extent. We know even though it’s best to be on anabolic first, many patients are started on bisphosphonates, and when those patients have a fracture or declining bone density, transitioning to an anabolic agent may be appropriate. One head-to-head study shows that transitioning to romosozumab is superior to transitioning to teriparatide in this setting. For patients who’ve been on denosumab previously who become very high risk because of a fracture on therapy or declining DMD or maybe they just remain at very high risk—they’re not having a great response to denosumab—anabolic treatment might also be appropriate. And in those patients, romosozumab appears to be better than teriparatide, but we still don’t really know the optimal approach for these patients. 

We know that it might be challenging for some healthcare providers to prescribe anabolic therapies, and I think if that’s the case, a referral to a specialist like an endocrinologist, rheumatologist, or a primary care provider who treats a lot of osteoporosis patients is very appropriate in order to make sure that patients are treated optimally.

Announcer:
That was Dr. Felicia Cosman talking about how we can identify the optimal treatment sequencing approach for patients with osteoporosis. To access this and other episodes in our series, visit On the Frontlines of Osteoporosis on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!