New medications for osteoporosis have broadened individualised treatment according to patient preference and specific clinical concerns. Sophisticated options for using new agents include combined or sequential prescribing, although PBS restrictions only allow suboptimal use of some agents.
- Osteoporosis is a common yet under-recognised condition, with high morbidity and mortality.
- ‘Traditional’ antiresorptive medications such as bisphosphonates, hormone replacement therapy and raloxifene are effective but have some limitations.
- Denosumab, a newer antiresorptive, has antifracture efficacy, and favourable 10-year safety data. It has generally similar side effects to bisphosphonates; however, hypocalcaemia is a potential risk particularly in people with stage 4 to 5 chronic kidney disease, and rebound-associated vertebral fractures have been observed after denosumab discontinuation. The role of denosumab in glucocorticoid-induced osteoporosis is under investigation.
- Teriparatide, the only available anabolic agent in Australia, is limited to 18 months’ use. After discontinuation, commencement of an antiresorptive agent is trongly recommended.
- Combining denosumab and teriparatide appears promising, with impressive gains in bone mineral density; however, no fracture data are available yet, and the ombination is not currently available on the PBS.
- Novel anabolic agents with phase III trial evidence include abaloparatide (a parathyroid hormone-related protein analogue) and romosozumab (an antisclerostin antibody).
- Although associated with significant fracture reduction in phase III trials, development of odanacatib (a cathepsin K inhibitor) has been discontinued because of a small increased risk of stroke.
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