Posts Tagged ‘Bisphosphonate’
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.
The biggest problem with oral Bisphosphonates is GI upset, especially Gastro-Esophogeal Reflux Disease (GERD). Another problem is that you must take them on an empty stomach – then eat nothing for 30 to 60 minutes. Atelvia attempts to evade those issues with enteric coating. Atelvia is Risedronate (Actonel) which does not disolve until in the small intestines. It can be taken with food. This is definitely more convenient.
Published studies show Atelvia to be as effective in decreasing fracture rates as daily Actonel (the orginal dosing of Risedronate). That is good.
The enteric coating should make GERD much less common than with regular Actonel. Surprisingly, there are no published studies to back up that obvious supposition. Nor are there any studies about other GI problems common with regular bisphosphonates. Fortunately, we do have some samples for patients to try in order to determine if they have any GI problems with Atelvia, before getting a paid-for prescription.
Atelvia is still new enough on the market that we have no long term experience. It may acquire the niche market for an oral Bisphosphonate without GERD.
Having an additional osteoporosis medication option is good.
Jay Ginther, MD