Osteoporosis
Table 3: Osteoporosis Treatments Generic Name (Brand) Fracture Type Reduced Dose and Frequency Administration
Calcitonin (Miacalcin®)60 Raloxifene (Evista®)61
Alendronate (Fosamax®)62
Vertebral Vertebral Vertebral and hip 200IU spray daily 60mg daily 5–10mg daily, 30–70mg weekly Nasal spray Tablet Tablet
Potential Long-term Side Effects
None
Blood clots and risk for dying from stroke ONJ, chest pain,
heartburn, swallowing problems, esophagus
problems, and atypical fractures
Ibandronate (Boniva®)63 Vertebral 2.5mg daily; 150mg monthly; 3mg infusion quarterly
Tablet or intravenous infusion
Swallowing problems, chest pain, heartburn, stomach/esophageal
ulcers, low calcium, pain in extremities, and atypical fractures
Risedronate (Actonel®)64
Non-vertebral, including hip
5mg daily;
30–35mg weekly; 150mg monthly
Tablet
Swallowing problems, chest pain, heartburn, stomach/esophageal
Back and joint pain, stomach, pain, flu-like symptoms, eye
ulcers, low calcium, pain inflammation, allergic, in extremities, ONJ, and and severe skin reactions atypical fractures
Zoledronic acid (Reclast®)65
Teriparatide (Forteo®)66
Vertebral, hip, and Non-vertebral
Vertebral and non-vertebral
Denosumab (Prolia®)67
Vertebral, hip, non-vertebral
ONJ = osteonecrosis of jaw.
rate of 79.1% for any fracture (for a threshold of 20%) and 79.5% for hip fracture (with a threshold of 3%).16
The nomograms were more effective
in their assessment of fracture risk owing to their higher accuracy in predicting fracture, especially hip fractures. This study used BMD results in its analysis.
In 2002, before the development of FRAX, COSC established risk factor-based guidelines to aid clinical judgment in combination with BMD. The COSC guidelines are similar to those of NOF: treat any patient with a T score below -2.5 and evaluate for treatment those with T scores below -1.5. COSC classifies risk factors as either major or minor (see Table 2). Treatment is recommended for patients with one major risk or two minor risk factors present. In addition, COSC recommends treatment for patients using prednisone 7.5mg daily, regardless of their T-score. This is the only guideline that incorporates a dose relationship. The use of the COSC risk factors is the simplest assessment method, but is dependent on BMD.
Treatment Options in Osteoporosis Once it has been decided that a patient is at risk for fracture based on their BMD and other risk factors, they should receive individualized
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The physician can then individualize pharmacological treatment based on efficacy and patient preferences. Multiple treatment options can be individualized based on the preferences of the physician and patient to maximize effectiveness and adherence.
Table 3 summarizes some of the major treatment options, including the type of fracture reduced by the medication, administration type, and frequency of administration. All medications are effective in reducing vertebral fractures but vary in their ability to reduce hip and non-vertebral fractures. Medications can be delivered orally daily, weekly or monthly, by intravenous infusion every three months or 12 months, or by subcutaneous injection daily or twice yearly.
Physicians should first begin with therapeutic agents that have robust fracture reduction across multiple sites, such as vertebrae, non-vertebrae, and hip. These therapies include alendronate, risedronate, ibandronate, zoledronate, denosumab, and teriparatide. For second-choice therapies, physicians can use selective estrogen
US MUSCULOSKELETAL REVIEW
treatment. Treatment advice from the physician should begin with lifestyle modifications, including regular exercise, smoking and alcohol cessation, and diet supplementation with calcium (12,000mg/day) and vitamin D (800–1,000IU/day).2
5mg infusion annually
20µg subcutaneous injection daily
60mg injection biannually
Intravenous infusion over 15 minutes
Kidney problems, ONJ, atrial fibrillation, and atypical fractures
Subcutaneous injection Increased calcium in blood
Subcutaneous injection ONJ, atypical fractures
Low blood calcium, bone, and joint pain
Decrease in blood pressure
when changing positions, nausea, joint pain, and osteosarcoma
Skin problems and serious
infections and hypocalcemia
Diarrhea, mild flu-like symptoms, and stomach pain
Short-term Side Effects
Nose bleed, runny nose, back and joint pain
Hot flashes, leg cramps, and feet swelling Flu-like symptoms, allergic reactions, and stomach pain
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