Anabolic drug (AD) options are currently limited to PTH analogs. With potent bone-forming effects, AD offer marked increases in BMD. However, the demonstration of their efficacy on fracture risk reduction was possibly limited by the early discontinuation of the pivotal trial for safety concerns. Therefore, their use must rely both in the available evidence as well as in the clinical judgment for the individual patient. Indeed, potential contraindications are the first step in deciding if we put our patient on AD. Not least, cost of treatment should be also weighted when indicating this treatment.
As a first-line option can be considered in cases of very advanced disease, measured in terms of BMD and existing fractures, with the objective of inducing a remission of the disease to, later on, continue with a maintenance therapy for consolidating the achieved gains in bone density and strength. Two options are possible, used alone or in combination with a potent antiresorptive even though the latter option remains in an investigational phase. More evidence on antifracture efficacy is needed for the combined use although offers a promising efficacy profile in cases at substantial risk of hip fracture.
Another scenario when AD can be considered as a first alternative might be in cases where risk factors for treatment failure to oral antiresorptives accumulate in a single patient. In this case the clinician could choose between an AD or a potent injected antiresorptive. Very similar decision is faced by the clinician when a patient has failed to oral antiresorptives, again with similar alternatives for switching therapy to an AD or a potent injected AR.
Finally, a third possibility is in cases of intolerance or, more importantly, side effects associated with the use of antiresorptives. Two main situations are under active research, cases of osteonecrosis of the jaw and atypical femoral fractures, when the patient still is at high risk of common fragility fractures.
New, more potent anabolics, better combined treatments or regimens, including non pharmacological interventions are the future for achieving the cure of osteoporosis, not just a decrease in risk, the best we can currently achieve.
17 May 2014 - 20 May 2014