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Selection of antiresorptive or anabolic treatments for postmenopausal osteoporosis

Nature Clinical Practice Endocrinology & Metabolism volume 4, pages 514–523 (2008)Cite this article

Abstract

Osteoporosis is a common, chronic disease that can be treated effectively by pharmacological interventions. Antiosteoporotic drugs reduce fracture risk via different mechanisms of action. Available therapies are broadly distinguished into inhibitors of bone turnover, stimulators of bone formation, and therapies with as-yet unclear mechanisms of action. No direct comparison studies with fracture end points have yet been done, which makes selection of one drug over another difficult. Identification of individuals who might derive particular benefit from a specific therapy has been explored in post-hoc analyses of clinical studies with bisphosphonates and recombinant parathyroid hormone (PTH). Their findings showed that the efficacy of these therapies in reducing fracture risk was largely independent of the prevalent rates of bone turnover. Selection of a specific antiosteoporotic therapy should, therefore, be made according to the results of trials specifically designed to assess fracture risk, safety, tolerability, patient preference and cost-effectiveness rather than on characteristics specific to patients or the disease. Studies of sequential administration of PTH and bisphosphonates suggest advantages over single-therapy regimens, particularly in patients with severe disease. However, the optimum duration of PTH administration, as well as the efficacy of such regimens in reducing the risk of fractures, remain to be determined.

Key Points

  • Osteoporosis can be treated effectively by inhibitors of bone turnover, such as bisphosphonates, or stimulators of bone formation, such as parathyroid hormone (PTH)

  • No direct comparisons of the efficacy of these different approaches to therapy with fracture end points have been done, which makes selection of one treatment over another difficult

  • Identification of individuals who might derive particular benefit from a specific therapy is also not possible

  • Choice of a specific antiosteoporotic therapy should be made on the basis of evidence of antifracture efficacy, safety, tolerability, patient preference and costs

  • Sequential treatment with PTH followed by a bisphosphonate might be advantageous over monotherapy with either of these drugs but further studies are needed to define the optimum duration of PTH administration and the efficacy of sequential regimens in reducing the risk of fractures

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Figure 1: Changes in bone turnover during treatment with antiresorptive and bone-forming agents.
Figure 2: Incidence of vertebral fractures in patients with postmenopausal osteoporosis 1 year and 3 years after treatment with either risedronate 5 mg daily or placebo.
Figure 3
Figure 4: Incidence of vertebral and nonvertebral fractures combined in patients with postmenopausal osteoporosis after treatment with parathyroid hormone1–34.
Figure 5: Changes in serum P1NP levels 1 month and 6 months after treatment with 20 µg parathyroid hormone1–34 daily in patients pretreated with inhibitors of bone resorption.

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  1. S Papapoulos is a Professor of Medicine and P Makras is a Clinical Fellow in the Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands.,

    Socrates Papapoulos & Polyzois Makras

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Correspondence to Socrates Papapoulos.

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Competing interests

Socrates Papapoulos acts as a consultant for Amgen, Eli Lilly, Merck & Co., Novartis, Procter & Gamble, Roche/GlaxoSmithKline and Wyeth, and is a member of the speakers' bureaus for all but Wyeth. He has received grant and/or research support from Merck & Co. and Procter & Gamble.

Polyzois Makras declared no competing interests.

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Papapoulos, S., Makras, P. Selection of antiresorptive or anabolic treatments for postmenopausal osteoporosis. Nat Rev Endocrinol 4, 514–523 (2008). https://doi.org/10.1038/ncpendmet0941

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