Osteoporosis Update 2017

Osteoporosis Update
New information continues to emerge in helping us to decide the best treatment for osteoporosis. We still encourage weightbearing exercise, smoking cessation and moderation in alcohol intake. Vitamin D supplementation (when vitamin D levels are low) is helpful. Taking calcium in foods high in calcium such as dairy products is desirable but supplementation with calcium pills can be done on a more limited basis than in the past. 600 mg of supplemental calcium is probably as much as should be taken. In patients who have a history of kidney stones, that can be a problem.
Medications fall in 2 major categories. There are antiresorptive medications including such drugs as Fosamax, Actonel, and Boniva along with Reclast given intravenously. The other group of drugs, Forteo and Tymlos, stimulate new bone growth and are discussed below.
Reclast can be given for 3 years in a row and then should be stopped for at least a year. We tend to not use much Boniva in our practice as the hip data for preserving bone with this drug is not impressive. We administer a lot of Prolia in our practice, an antiresorptive with a slightly different mechanism of action than the previous drugs. This drug is given every 6 months subcutaneously in the office. All of these drugs have extremely rare side effects including jaw necrosis and long bone fractures (i.e. in the femur). Of the thousands of patients whom we treat with osteoporosis, we have not seen these side effects in the last 13 years. Hopefully, we are more attentive to these problems and have been able to avoid them.
The length of time one can be on Prolia is not entirely clear Studies have demonstrated continued benefit from Prolia on bone structure out to 10 years. There are studies showing that stopping Prolia may be accompanied by an increase in fractures in the year following Prolia cessation. Some experts advocate stopping Prolia after about 8 years and using Reclast in its place for a year or two since there is still the concern that prolonged use of Prolia, like the bisphosphonates (i.e. Fosamax) might be associated with long bone fractures. This probably seems confusing as there are reasons to continue Prolia and reasons to stop even if temporarily while substituting something else. Time and more studies will settle this issue.
In the meantime, a new bone building drug has been released, Tymlos. Like Forteo, it is a daily injection. Unlike Forteo, it is used for 18 months instead of 24 months for Forteo. It does not need to be refrigerated. The pen which contains 30 injections is a bit unwieldy compared to the Forteo pen and depending on the hand agility of the patient, might be an issue. These drugs are used when the anti-resorptive drugs fail or if the patient has a fragility fracture (i.e. falling from a standing position). Results are encouraging. Patients who have had previous radiation (for cancer) generally cannot use Forteo or Tymlos but exceptions sometimes are made.

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