Targeted treatment for osteoporosis

     Current treatment for osteoporosis has evolved from a traditional response-to-treatment approach to a goal-directed approach. The core concept of targeted treatment is to ensure each patient receives the most appropriate medication to reduce fracture risk as quickly and effectively as possible. The ultimate goal of treatment is to remain fracture-free.

     Targeted therapy emphasizes equity over equality; that is, treatment must be tailored to each individual's characteristics. Treatment goals and treatment selection must therefore be individualized, based on information from fracture history, prevalence of vertebral fractures, time elapsed since fracture, age, and bone density in the spine and hip.

 

Selecting Treatment Targets

 

The choice of treatment goal depends on the patient's initial risk factors:

1. Patients with an imminent risk of fracture.

     This patient group includes those with a > 10% risk of fracture within 2 years, those with a recent clinical fracture (< 2 years), those with a vertebral fracture detected on radiography, and those with a history of multiple fractures.

The goal of treatment: To rapidly and maximally reduce fracture risk.

2. Patients with no immediate risk (Non-imminent Risk)

For this patient group, the focus will be on improving the BMD T-score, with the Total Hip as the primary indicator, as research has shown that changes in Total Hip BMD are the best predictor of fracture risk reduction ^.

         - Baseline T-score < -2.5

Treatment goal: Increase the T-score to > -2.5, and potentially aim higher to > -2.0, especially if the patient has a history of fracture or other major risk factors.

        - Baseline T-score > -2.5

 

 

     Treatment goal: To achieve a at least 3% increase in BMD at the total hip and a 5% increase at the lumber spine, as higher BMD is associated with a reduced fracture risk.

 

Selecting Treatment

1. Treatment for patients with imminent risk of fracture.  

     Since the goal is to reduce fracture risk as quickly and as much as possible, anabolic agents such as teriparatide, abaloparatide, and romosozumab are the best option to achieve this goal. Comparative studies have shown that anabolic agents are more effective than antiresorptive drugs in reducing fracture risk, such as the VERO study ² (Teriparatide > Risedronate) and the ARCH study ³ (Romosozumab > Alendronate).

2. Treatments to achieve BMD targets.

     The choice of first-line medication should consider its ability to increase BMD and the probability of achieving the target T-score within a reasonable timeframe (approximately 3 years) to achieve a T-score > -2.5 in more than 50% of patients receiving each medication, as shown in the table.

 

3. Selection of continuation treatment from anabolic agents

     Upon completion of 2 years of treatment with teriparatide or 1 year of treatment with romozosumab, treatment with antiresorptive drugs is crucial for maintaining BMD. The principle is asfollows

 - If a patient's BMD is close to the target BMD, such as -2.5 (or -2.0), bisphosphonates may be a more suitable option because there is a possibility of a temporary drug holiday after the BMD target is reached. If the patient's BMD is still far from the target, long-term or extended period of denosumab administration is likely a better option, as denosumab is more effective than bisphosphonates in increasing BMD and reducing the risk of fractures.

 

     If an additional course of anabolic treatment is considered, bisphosphonates may be a more suitable option to maintain drug efficacy for subsequent treatment cycles.

 

 

Source : Doctorwat