Osteoporosis, An Issue of Rheumatic Disease Clinics

Stuart L. Silverman

Description

This timely and evocative issue of Rheumatic Disease Clinics explores important current and controversial topics in the treatment of osteoporosis. And it answers some tough questions! Here are some examples. How long do I treat my patient? Is there a place for bone turnover markers? How much Vitamin D should I recommend? Controversies around calcium and Vitamin D are explored regarding the coronary risk and pancreatic issues. Emerging therapies are presented, including sclerostin and oral calcitonin. Long-term safety concerns of antiresporptive therapy (ONJ, atypical fracture, would healing) are explained. The utility and limitations of FRAX are covered, as well as Prolia and the RANKL pathway. An update on glucocorticoid induced OP is given. The reader is also brought up to date on men’s health issues and OP. This is an essential issue for any practicing rheumatologist to stay current in the field.

Sujets

• Medical
• Médecine
• Rheumatology

Informations

• Publié par: Saunders
• Date de parution: 28 août 2011
• Nombre de lectures: 0
• EAN13: 9781455709533
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Rheumatic Disease Clinics of North America , Vol. 37, No. 3, August 2011
ISSN: 0889-857X
doi: 10.1016/S0889-857X(11)00050-0

Contributors
Rheumatic Disease Clinics of North America
Osteoporosis
Stuart L. Silverman, MD
Cedars-Sinai bone Center of Excellence, 8641 Wilshire Boulevard, Suite 301, Los Angeles, CA 90211
ISSN  0889-857X
Volume 37 • Number 3 • August 2011

Contents
Cover
Contributors
Forthcoming Issues
Osteoporosis
Duration of Treatment in Postmenopausal Osteoporosis: How Long to Treat and What are the Consequences of Cessation of Treatment?
Emerging Therapies for Osteoporosis
Calcium and Vitamin D Controversies
Is There a Place for Bone Turnover Markers in the Assessment of Osteoporosis and its Treatment?
Long-term Safety Concerns of Antiresorptive Therapy
Osteoporosis in Men: Update 2011
Update on Glucocorticoid-Induced Osteoporosis
The RANKL Pathway and Denosumab
Assessment of Fracture Risk
Teriparitide Update
Index
Rheumatic Disease Clinics of North America , Vol. 37, No. 3, August 2011
ISSN: 0889-857X
doi: 10.1016/S0889-857X(11)00052-4

Forthcoming Issues
Rheumatic Disease Clinics of North America , Vol. 37, No. 3, August 2011
ISSN: 0889-857X
doi: 10.1016/j.rdc.2011.08.003

Preface
Osteoporosis

Stuart L. Silverman, MD
Cedars-Sinai Bone Center of Excellence, 8641 Wilshire Boulevard, Suite 301, Los Angeles, CA 90211, USA
E-mail address: [e-mail]


Stuart L. Silverman, MD, Guest Editor
This issue of Rheumatic Disease Clinics of North America is dedicated to the efforts of rheumatologists worldwide to study, diagnose, and treat osteoporosis. Rheumatologists are uniquely positioned to treat osteoporosis as patients with osteoporosis often present with the painful symptoms of fracture. Rheumatologists treat patients with diseases associated with increased risk of fracture such as rheumatoid arthritis or use medications like glucocorticoids, which increase the risk of fracture. Rheumatologists are often the champions for osteoporosis in their own institutions and local communities.
Rheumatologists have taken the lead in many aspects of the osteoporosis world globally, nationally, and locally. Rheumatologists have led national organizations such as International Society of Clinical Densitometry (ISCD) and American Society for Bone Mineral Research (ASBMR).
The American College of Rheumatology or ACR has had a study group in osteoporosis metabolic bone disease for almost two decades. The ACR has taken the lead in developing guidelines for glucocorticoid-induced osteoporosis.
Rheumatologists have participated in ASBMR taskforces on system-wide intervention, osteonecrosis of the jaw, and atypical fractures.
Rheumatologists have participated in developing new accreditation criteria for osteoporosis for the Joint Commission.
Rheumatologists have taken the lead studying the health-related quality-of-life impact of osteoporosis.
In this issue, we invited rheumatology osteoporosis experts and their colleagues to discuss the ten following topics related to the assessment and treatment of osteoporosis.
1. Sandy Baim from the University of Miami updates us on the strengths and limitation of FRAX, the new WHO fracture risk algorithm, which helps us to target the patients who need treatment the most.
2. David Silver from Cedars-Sinai tries to make sense of the current calcium and vitamin D controversy.
3. Jie Zhang, Ken Saag, and Jeff Curtis from the University of Alabama at Birmingham address the adverse effects associated with long-term bisphosphonate therapy and discuss osteonecrosis of the jaw and atypical fractures.
4. Andy Laster from Arthritis and Osteoporosis Consultants of the Carolinas, and Bobo Tanner from Vanderbilt University have cogently reviewed the issues of discontinuing long-term bisphosphonate therapy and possibly taking a holiday. We can no longer treat patients with risk for fracture with a single drug during their lifetime.
5. Robin Dore from UCLA shares with us new data of up to 5 years on denosumab, the first RANK-ligand inhibitor.
6. Mike Maricic from the University of Arizona updates us on glucocorticoid osteoporosis, both the identification of patients who should be treated by ACR criteria as well as the new management options.
7. As we begin to place our bisphosphonate patients on holidays, the importance of being able to monitor patients has increased. J.P. Devogelaer, Yves Boutsen, Damein Gruson, and Daniel Manicourt from the Université Catholique de Louvain give us some guidelines on the place of bone turnover markers in osteoporosis assessment and treatment.
8. Denise Orwig, Nancy Chiles, Mark Jones, and Marc Hochberg from the University of Maryland update us on the treatment of osteoporosis in men.
9. Chad Deal from the Cleveland Clinic discusses exciting data on new osteoporosis drugs, particularly the new anabolics.
10. Finally, with my colleague Keaton Nasser from Cedars-Sinai, I discuss an update on teriparatide, the first approved anabolic therapy.
Enjoy!
Rheumatic Disease Clinics of North America , Vol. 37, No. 3, August 2011
ISSN: 0889-857X
doi: 10.1016/j.rdc.2011.07.007

Duration of Treatment in Postmenopausal Osteoporosis: How Long to Treat and What are the Consequences of Cessation of Treatment?

Andrew J. Laster, MD a , * , S. Bobo Tanner, MD b , c
a Arthritis & Osteoporosis Consultants of the Carolinas, 1918 Randolph Road, Suite 600, Charlotte, NC 28207, USA
b Division of Rheumatology, Vanderbilt University Medical Center, 2611 West End Avenue, Suite 210, Nashville, TN 37203, USA
c Division of Allergy & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
* Corresponding author.
E-mail address: [e-mail]

Abstract
Although a variety of medications are effective for the treatment of postmenopausal osteoporosis, there is concern that long-term use may incur side effects. Consequently, some have proposed discontinuing or temporarily suspending treatment after a defined period of time. As the benefits of fracture risk reduction may recede during this “drug holiday”, the clinician may be faced with deciding when to resume therapy (and with which agent) while avoiding the possible cumulative risk of side effects. This article summarizes data regarding length of treatment and the effects of cessation of treatment on bone density, bone turnover markers, and fracture risk.

Keywords
• Osteoporosis • Drug holiday • Fracture risk • Bisphosphonate • Teriparatide • Raloxifene • Denosumab • Estrogen
There are few concerns about the consequences of long-term treatment of chronic disease except when the drugs being used accumulate within the body. Rheumatologists are well aware of the affinity of the choloroquines for the retina and its resulting ocular toxicity in select individuals. Bisphosphonates avidly bind to hydroxyapatite within bone and have limited biological degradation. 1 - 3 Although causality has not been definitively established, concern that bisphosphonate therapy could lead to specific bone toxicities such as osteonecrosis of the jaw (ONJ), and atypical fractures can be appreciated in this construct. Whether other potent antiresorptives such as denosumab, which do not bind to bone, have similar toxicities remains unanswered at this time.
In addition, there has been an appreciation that patients who have been treated with select bisphosphonates for several years could stop taking the drug without a rapid decline in bone density or increase in markers of bone resorption. Some have taken this residual effect on bone density and bone turnover markers to imply continued fracture benefit even after drug cessation. However, studies demonstrating persistent fracture benefit are limited.
This review examines the different drug therapies currently approved by the Food and Drug Administration (FDA) for use in the management of postmenopausal osteoporosis, and evaluates the current data regarding effects of discontinuation on bone mineral density (BMD), bone turnover markers (BTM), and fracture risk reduction. The authors attempt to provide a general framework for clinicians to determine which patients are appropriate candidates for discontinuation of medical therapy, temporary suspension (drug holiday), and continued treatment. Two other excellent reviews on this topic with somewhat contrasting recommendations have appeared within the last 2 years, by Seeman 4 and Watts and Diab. 5
There are other questions implicit in this discussion. What is the optimal duration of treatment with these agents in achieving fracture reduction and avoiding side effects related to cumulative exposure? What effect does a “holiday” have on the reduction of the risk of side effects? Does resumption of treatment after a holiday resume the risk? Does a change from an antiresorptive agent to an anabolic agent reset the cumulative risk of the antiresorptive agent back to baseline? Does a change in the mechanism of antiresorptive treatment (eg, bisphosphonate versus denosumab) change the cumulative risk? Unfortunately, there are currently few data to guide the answers to these important questions, yet clinicians are faced with these decisions daily.

Discontinuing osteoporosis treatment

The Effect on Bone Mineral Density and Bone Turnover Markers
Cessation of osteoporosis treatment has been shown to have