Posts Tagged ‘Bisphosphonate’
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
Recent studies have shown that the order in which we use osteoporosis medications matters. Traditionally most docs have used Antirsorptives first to preserve bone. All osteoporosis medications except one are Antiresorptives. Only when that failed, would they consider the Anabolic medication, Forteo, to build new bone.
As a practicing orthopedic surgeon, I started treating osteoporosis in the worst of my fracture patients. It was obvious that they needed to build bone first since there was very little bone to preserve. Therefore, I usually started with the Anabolic, Forteo. Once I had built up the bone, I preserved that improved bone with an Antiresorptive osteoporosis medication.
As the National and International Osteoporosis Foundations, (NOF and IOF) are now focusing on preventing second fractures, many more practioners are treating patients with one or more fractures. They are facing the dillema of how to prevent fractures in bone that is not good enough. None of the Antiresorptives work as well in patients with multiple fractures as they do in patients who have not yet fractured.
This year studies have shown that using Forteo after an Antiresorptive usually results in Forteo taking several months to overcome the previous slowing of bone turnover, Therefore, 2 years of Forteo results in less improvement when used AFTER the Antiresorptives tested, than we normally see in a patient who uses Forteo first.
At NOF and IOF this year speakers suggested that we change our approach. They suggested using an Anabolic first, and an Antiresorptive second should be the standard sequence for best results.
Would you rather only trying to preserve your bones after they have proven insufficient in multiple fractures? Or would you want to improve your bone first, and then prserve that improved bone matrix and improving BMD?
Do everything you can to improve and preserve your Bone Health.
Jay Ginther, MD
Recently a patient asked me to review all osteoporosis medications for her to consider and choose from. We had already optimized her Calcium intake, 25-hydroxy Vitamin D level, Protein intake, Multiple Vitamins & Minerals, and Exercise program. These had all helped substantially, but not enough for her peace of mind. She feels that she needs osteoporosis medication too. Here they are:
Denosumab (Prolia) mimics the natural process that keeps OsteoClasts (the cells that gobble up bone) under control before menopause. OsteoCytes release Osteoprotegrin (OPG) when Estrogen (or Testosterone) is on board. OPG controls the formation and activation of OsteoClasts by blocking RANK-Ligand, which is necessary for OsteoClast formation and activation. This decreases fracture risk.
Prolia mimics OPG and blocks RANK-Ligand, thus blocking bone resorption by preventing OsteoClasts. It is a RANK-Ligand Antibody. It is like birth control for OsteoClasts. Prolia is given as a shot under the skin twice a year. Prolia is very effective at first, but begins to fade by 6 months. Without another injection , Prolia has totally lost effectiveness by 12 months after the last shot.