Posts Tagged ‘antiresorptive’
National Bone Health treatment goals are changing for those patients with high fracture risk. Simply preserving bones already at a too high fracture risk never made much sense to this former orthopedic surgeon. Now the national leadership is stressing the need to lower fracture risk first, then preserve bones at a lower level of fracture risk.
We now have 3 anabolic medications which substantially lower fracture risk by increasing the thickness and strength of bone structure: Teriparatide (Forteo), Abaloparitide (Tymlos), and Romosozumab (Evenity). They all decrease fracture risk substantially more than the antiresorptive (preserving) medications alone. The difference in fracture risk grows for up to 5 years. After that the difference in fracture risk between anabolic meds followed by preserving meds vs. preserving meds alone remains the same.
Calcium can take up to 3 additional years to collect in newly formed bone matrix. DXA shows calcium in bone (Bone Mineral Density). Much of the increased BMD can only be seen on DXA after the anabolic med is completed and the antiresorptive med is started.
All of the anabolic medications must be followed by antiresorptive medication to preserve the gains made by the anabolic. No medication to grow or preserve bone can work without adequate nutrition in the form of absorbable calcium, vitamin D3, protein and other vitamins and minerals.
Jay Ginther, MD
We now have a third anabolic medication to build new bone. Evenity is really different from the other anabolics, Forteo (teriparatide) and Tymlos (abaloparatide). Forteo and Tymlos are daily shots based on the human hormones PTH and PTHrP. Evenity is an antibody to the human hormone sclerostin.
Sclerostin controls bone formation by telling osteoblasts to stop making new bone, and telling osteoclasts to gobble up old bone. This results in stable bone turnover remodeling (until menopause decreases control over the osteoclasts and they go wild). Evenity suppresses sclerostin.
Evenity markedly increases new bone matrix formation within the first month.However, the ability of Evenity to increase new bone formation diminishes month by month until it is mostly gone by one year. Therefore, it has been approved for use for only one year at a time. Like Forteo and Tymlos, Evenity must be followed by an antiresorptive to preserve the increase in bone.
Evenity also suppresses bone resorption by the second month. This is a less dramatic action, but it continues at the same level to the end of the year. The net result is a significant increase in bone matrix by the end of the year, in the same general order of magnitude as Forteo and Tymlos.
Evenity is a monthly shot into the subcutaneous fat on the back of both arms by a healthcare professional.
There is a possibility that Evenity may increase cardiac events in persons who have had a recent stroke or heart attack. This was found in only one of the 3 clinical trials of Evenity.
Preauthorization is required for insurance to cover Evenity. Most insurances will probably cover it within the first 3-12 months. More next time.
Jay Ginther, MD
Our goal is NO NEW FRACTURES. Therefore, Treat to Target means a FRAX score of <20% for “major osteoporotic” and <3% for hip fracture. Alternately, T-score of better than -1.5 if there are any fractures.
Antiresorptives do not substantially increase bone mass or BMD. While a 3-5% BMD improvement can be seen when a long term deficiency in calcium absorption is corrected, the function of an antiresorptive is to maintain current bone mass.
If you want to substantially increase bone mass, you must use an anabolic medication. We now have 2. Forteo (teriparatide) has been available for 15 years. Tymlos (abaloparatide) was approved late last spring, but has only achieved good coverage by a majority of insurance companies in the last month.
Both can be given for up to 24 months. Both must be followed by an antiresorptive to avoid loss of gains. Both will show continued improvement in BMD for up to 3 years after switching to an antiresorptive because calcium takes up to 3 years to fully accumulate in new bone matrix formed by an anabolic.
Both should NOT be given to anyone with open growth plates, Paget’s, radiation to bone, cancers which have or could spread to bone, elevated bone specific alkaline phosphatase other than from fracture healing, or pregnant or nursing women.
Tymlos is approved for postmenopausal women only. It does not stimulate bone turnover significantly and therefore shows faster BMD increase initially in the hip. It has not been tested for use after antiresorptives.
Forteo is approved for men and women with osteoporosis which is “age-related”, or from steroid use, or from idiopathic hypogonadism. Forteo significantly increases both osteoblast and osteoclast activity, thereby stimulating bone turnover, which is often suppressed after long-term antiresorptives. Forteo is the default treatment for ONJ and AFF.
If you are dealing with vertebral fractures on VFA, or really low BMD on DXA, or with multiple fragility fractures, you need an ANABOLIC FIRST, to decrease fracture risk. Then follow with antiresorptives to maintain a low enough fracture risk.
Remember, even these medications will fail without proper nutrition.
jay Ginther, MD
The FDA approved Tymlos (Abaloparatide) in June for use in women diagnosed with osteoporosis. Unfortunately most patients are unlikely to obtain insurance coverage for Tymlos until January or February 2018.
Tymlos is an anabolic, which means that it can stimulate osteoblasts, the cells that make new bone matrix. Until now only Forteo (Teriparatide) has been available to do that. Having a second option will be helpful.
Tymlos is similar to Forteo, yet there are distinct differences. Tymlos is almost pure osteoblast stimulation which means that BMD rises faster in areas with cortical bone, such as the hip. This potentially makes it a better choice for women never exposed to antiresorptive bisphosphonates like Fosamax (Alendronate), Actonel (Risedronate), Boniva (Ibandronate), and Reclast.
Tymlos is a daily shot (like insulin), but does not require refrigeration. It is approved for up to 24 months use and must be followed by an antiresorptive in order to not lose the benefits gained.
Patients with a single fracture of hip, or multiple fractures of other bones including spine, or with a BMD well below -2.5, or a FRAX score well above 20%and 3.0%, should be considered for an anabolic. Now we have another choice available.
For now Tymlos is approved for women only and osteoporosis only. We look forward to the FDA adding men and other indications in coming years.
Meanwhile, we wait for insurance coverage to make it affordable.
Jay Ginther, MD