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Monitoring osteoporosis treatment effect with bone turnover markers may improve compliance
Eekman D. BMC Musculoskelet Disord. 2011. doi:10.1186/1471-2474-12-167.
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Measuring the suppression of bone turnover markers may be a valuable tool for monitoring early osteoporosis treatment effect and persistence to therapy, according to researchers in the Netherlands.
“A decrease in bone turnover greater than the least significant change can be observed in the majority of newly treated patients,” wrote Danielle E. Eekman, MD, VU University Medical Center, Amsterdam, the Netherlands. “In chronically treated patients, 95% have a bone turnover in the premenopausal range. … Monitoring treatment effect with BTMs (bone turnover markers) in daily practice is feasible, and might be an additive tool in improving therapy compliance.”
Eekman and colleagues measured bone turnover markers in two groups: 31 newly diagnosed patients who were starting osteoporosis treatment and 95 patients already diagnosed with osteoporosis who had been treated with bisphosphonates for at least 3 months.
The researchers assessed how many patients had a decrease of serum levels of procollagen type 1 N-terminal propeptide (P1NP) and C-terminal crosslinking telopeptide (CTX) greater than the least significant change after 3 months of treatment. They evaluated how many patients treated with bisphosphonates for more than 3 months reached the biological goal of therapy, that is, bone turnover markers in the lower half of the normal premenopausal range.
The results showed that 25 patients in the newly diagnosed group (81%) had a decrease greater than the least significant change of both markers. In 95% of the patients in the second group, the serum P1NP and CTX levels were in the lower half of the premenopausal range, the authors wrote.
Monitoring initial treatment of osteoporosis with bisphosphonates is as important as monitoring cholesterol after statin treatment. It may be more important for the non-menopausal osteoporotic population. These tests can be performed early after initiation of treatment and are more sensitive than BMD. However, improving compliance remains problematic.
Treatment of osteoporosis prior to clinical fractures has been a "hard sell" going back to estrogens where compliance was poor at best: 30% -35%. Duration of treatment, no fractures, news of drug complications and costs are stronger forces of non-compliance than monitoring devices afford. More patients are aware of fractures secondary to bisphosphonates than they are the disease itself and its consequences. Patient compliance will only improve with medical leadership , patient education , specialized centers, and routine follow up visits for osteoporosis . Testing adds sophistication, but not necessarily facilitation.
— Douglas E. Garland, MD
Orthopedics Today
Editorial Board Member
Bone markers play a critical role in the treatment of metabolic bone diseases, including osteoporosis. Elevation of bone markers — especially those measuring bone resorption (N-telopeptide, C-telopeptide) — rise early with the onset of post-menopausal osteoporosis. They indicate an acceleration of osteoclastic resorption and mirror the loss of trabecular interconnectivity. Anti-catabolic agents including the bisphosphonates, denosumab, SERMs, and calcitonin primarily work by ceasing osteoclastic drugs. Therefore, upon initiating anti-catabolic drugs there should be a rapid (within 6 weeks) decline in the resorptive markers by at least 30%. Failure to achieve this goal indicates problems of compliance, absorption or dosage. Patients on prolonged bisphosphonate therapy retain these drugs and can over suppress the normal level of bone turnover. Consequently, if the resorption markers are too low (NTX <15) consideration would be warranted for a change of dose (lower, drug holiday). Although bone marker levels are not sufficient alone to initiate osteoporotic intervention, they are powerful diagnostic tools to monitor drug usage and dosage.
— Joseph M. Lane, MD
Hospital for Special Surgery
New York, NY