Correct therapy sequence ‘essential’ for patients with osteoporosis
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SAN DIEGO — Matching the correct therapy sequence to the right patient is critical when caring for patients with osteoporosis, according to a speaker at the Congress of Clinical Rheumatology West.
“Anabolic followed by antiresorptive is essential,” E. Michael Lewiecki, MD, of the University of New Mexico Health Sciences Center, told attendees during his presentation. “Initial treatment with an anabolic is ideal for those patients who have a very high fracture risk.”
He added that step therapy remains a major hurdle for physicians treating patients with osteoporosis.
“I think you are all fully aware of what has been called ‘step therapy,’ or ‘fail first therapy,’” Lewiecki said. “Health plans love this. It means you start with the cheapest drug.”
Often, the first step in this sequence for patients with osteoporosis is a low-cost generic antiresorptive medication, such as alendronate (Fosamax, Merck), according to Lewiecki. Following contraindication, a poor result or an emergent adverse event, a switch to a different antiresorptive is often made. Following step-two failure, a more potent antiresorptive or anabolic medication may be considered, Lewiecki said.
“This is what we have to deal with, and is the reality of medicine,” he said.
However, when weighing treatment options outside of the limitation of step therapy, it is imperative to consider all of the factors involved, from the patient’s fracture risk and drug adherence, to medication costs and treat-to-target goals, he added.
“When we are deciding how to start treatment, we think about what the level of risk is,” Lewiecki said. “We have to consider patient preference and their biases.”
Other key considerations include the patient’s expected adherence, age, sex, comorbidities, regular doses and even their primary mode of transportation, he added.
Finally, Lewiecki argued that it is important to weigh the sequence of therapy types and match them to the patients who will benefit the most.
For example, following an antiresorptive therapy with an anabolic therapy may delay the anabolic effect, Lewiecki said. Meanwhile, following anabolic therapy with antiresorptive is the best option for patients facing a high risk of fracture, he added.
“Anabolic followed by anabolic is probably neutral,” Lewiecki said. “Antiresorptive followed by antiresorptive may be neutral in some cases, but we do know that denosumab [Prolia, Amgen] increases bone density more than bisphosphonate.”
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Lewiecki EM. Sequential therapy in osteoporosis: When does the order matter? Presented at: Congress of Clinical Rheumatology West; Oct. 20-23, 2022 (hybrid meeting).
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