Other Antiresorptive Therapies

Other treatments include hormone replacement therapy (estrogens), selective estrogen receptor modulators, calcitonin, and monoclonal antibodies. Denosumab, which binds to receptor activator of nuclear factor κ-B ligand (RANKL inhibitor), prevents osteoclast formation and is recommended as initial treatment for postmenopausal women with a high fracture risk.21 The medication is delivered by a subcutaneous injection every 6 months. Once the patient stops using the medication, a rise in bone turnover and a decline in BMD occurs; therefore, to preserve bone density gains, another antiresorptive should be started immediately when denosumab is discontinued.11

Two parathyroid analogs (teriparatide and abaloparatide) are also on the market. These agents are recommended for postmenopausal women with osteoporosis (without cardiovascular risk factors) who are at very high risk for fractures. The duration of use should not exceed 2 years, since safety and efficacy of the agents for greater than 2 years has not yet been established.19,21 Delivered by daily subcutaneous injection, these drugs regulate bone metabolism and internal calcium absorption.19 When parathyroid analog treatment is completed, other antiresorptive therapy should be initiated.

Similarly, the newest anabolic agent, romosozumab-aqqg, a sclerostin inhibitor, is administered subcutaneously monthly for 12 doses, during which time, bone formation is increased and to a lesser extent bone resorption is decreased. Denosumab should be administered after completing the 12-dose regimen of romosozumab-aqqg, if osteoporosis treatment is still warranted.22

If women are unable to take bisphosphonates and denosumab, alternative therapy includes selective estrogen receptor modulators, such as raloxifene or bazedoxifene.19 Raloxifene is approved for both prevention and treatment of osteoporosis in postmenopausal women and bazedoxifene is approved for prevention.11 Women must be at low risk for deep vein thrombosis to be prescribed these agents. An added benefit of raloxifene or bazedoxifene is reducing the incidence of invasive breast cancer, which may be helpful in determining the appropriate patient population for use of these agents.21


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Patient Education

For patients who have already had a VCF or have osteopenia/ osteoporosis, adequate monitoring, treatment, and follow up must occur. Education and regular exercise programs aimed at reducing falls improve patient self-efficacy with respect to osteoporosis and fall risk and may lower rates of osteoporosis-related fractures.23 Encouraging patients to engage in healthy bone lifestyle habits also has positive ramifications for overall health.

Karen D. French, DNP, FNP-C, RN, is clinical director of the Family Nurse Practitioner Programs at Azusa Pacific University, in Azusa, California.

References

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2. International Osteoporosis Foundation. What is osteoporosis? IOF website. https://www.osteoporosis.foundation/. Accessed October 7, 2020.

3. Singer A, Exuzides A, Spangler L, et al. Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States. Mayo Clin Proc. 2015; 90(1):53-62.

4. Wright N. The burden of osteoporosis in the United States – a US bone and joint initiative report. American Society for Bone and Mineral Researchannual meeting. September 22, 2019. Abstract 1079.

5. Hammad LF, Benajiba N. Lifestyle factors influencing bone health in young adult women in Saudi Arabia. Afr Health Sci. 2017;17(2):524-531.

6. Fung TT, Arasaratnam MH, Grodstein F, et al. Soda consumption and risk of hip fractures in postmenopausal women in the Nurses’ Health Study. Am J Clin Nutr. 2014;100(3):953-958.

7. Shieh A, Greendale GA, Cauley JA, Karvonen-Gutierrez C, Crandall CJ, Karlamangla AS. Estradiol and follicle-stimulating hormone as predictors of onset of menopause transition-related bone loss in pre- and perimenopausal women. J Bone Miner Res. 2019;34(12):2246-2253.

8. Elhakeem A, Frysz M, Tilling K, Tobias JH, Lawlor DA. Association between age at puberty and bone accrual from 10 to 25 years of age. JAMA Netw Open. 2019;2(8);e198918.

9. Cai S, Yu H, Li Y, et al. Bone mineral density measurement combined with vertebral fracture assessment increases diagnosis of osteoporosis in postmenopausal women. Skeletal Radiol. 2020;49(2):273-280.

10. deVilliers TJ. Should women be screened for osteoporosis at midlife? Climacteric.            2018;21(3):239-242. 

11. National Osteoporosis Foundation. Healthcare professionals toolkit. https://www.bonesource.org/healthcare-professionals-toolkit 2019. Accessed September 27, 2020.

12. Alexandru D, So W. Evaluation and management of vertebral compression fracture. Perm J. 2012;16(4):46-51.

13. United States Preventive Services Task Force. Final recommendation statement: osteoporosis to prevent fractures: screening. June 26, 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening. Accessed October 7, 2020.

14. Qaseem A, Forciea MA, McLean RM, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(11):818-839.

15. Gillespie CW, Morin PE. Trends and disparities in osteoporosis screening among women in the United States, 2008-2014. Am J Med. 2017;130(3):306-316.

16. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332(12):767-773.

17. Angin E, Erden Z, Can F. The effects of clinical Pilates exercises on bone mineral density, physical performance and quality of life of women with postmenopausal osteoporosis. J Back Musculoskelet Rehabil. 2015;28(4):849-858.

18. Movassagh EZ, Vatanparast H. Current evidence on the association of dietary patterns and bone health: a scoping review. Adv Nutr. 2017;8(1):1-16.

19. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2019;104(5):1594-1622.

20. Epocrates. Osteoporosis. https://online.epocrates.com/results?query=Osteoporosis.  Accessed October 7, 2020.

21. Langdahl B. Management of endocrine disease: treatment breaks in long-term management of osteoporosis. Eur J Endocrinol. 2019;180(1):R29-R35.

22. Evenity [package insert]. Thousand Oaks, CA: Amgen; 2020.

23. Park KS, Yoo JI, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and vitamin D dietary intake in community dwelling elderly. BMC Public Health. 2017;17(1):966.