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
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.
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