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Pain Management: New osteoporosis treatment: Increasing bone mass

News-Journal - 1/13/2020

Our bones contain two different cell groups that, when working as a team, keep bones healthy. One cell group includes osteoclasts, cells that break down bone, creating microscopic pits in the bone surface. The other group includes osteoblasts, cells that form new bone to fill in these holes. This process of bone formation and absorption, called "bone remodeling," preserves bone health throughout our lives. However, when the "clasts" surpass the "blasts," bone density decreases, potentially causing osteoporosis and related fractures.

Women in their 40s lose about 1% of bone mass from their spines each year and during menopause the rate increases to 3% or more. After menopause, decreased estrogen leads to the increase of an essential mediator of osteoclast activity, RANK ligand. Bisphosphonates, such as Fosamax, Actonel, Boniva or Reclast, can inhibit osteoclast activity by directly causing osteoclast death. But Prolia (demosumab), a biologic agent, targets and binds to RANK ligand, inhibiting osteoclast formation, function and survival. Prolia is administered subcutaneously (under the skin) by a healthcare professional every six months. Bisphosphonates and Prolia are anti-absorptive agents, which inhibit osteoclast activity, reduce bone absorption and increase bone mass.

Other drugs, such as romosozumb, teriparatide and abaloparatide, are anabolic agents that increase osteoblast activity and promote bone formation. Scleostin is an inhibitor of osteoblast activity. Romosozumb (Evenity) is a type of antibody that binds to the structural protein sclerotin, preventing its inhibitor effects and increasing bone formation. Evenity is approved to treat osteoporosis only in postmenopausal women, at high risk of fracture. Evenity is administered subcutaneously once a month for one year. Since Evenity may increase the risk of myocardial infarction and cardiovascular death, it should not be initiated in patients who have had a myocardial or stroke within the preceding year.

Final medications to consider are Forteo (teriparatide) and Tymlos (abaloparatide), synthetic forms of parathyroid hormone. These drugs simulate the biologic effects of our parathyroid gland. Unlike anti-resorptive agents, Forteo and Tymlos work by stimulating osteoblasts and enhancing new bone growth, as opposed to just preventing further bone loss. Evenity, Forteo and Tymlos work much quicker and more effectively to increase bone production in the spine and hips than anti-absorptive drugs, yet they are more expensive than other anti-osteoporosis drugs. Moreover, Forteo and Tymlos must be administered daily. Currently, these medications are recommended for patients with severe osteoporosis, a history of osteoporotic fracture, and an inability to tolerate bisphosphonate therapy.

Forteo and Tymlos therapy programs are restricted to two years and Evenity to one year. It is important to note that the beneficial effects quickly diminish after discontinuing treatment. To maintain benefits and maximize effectiveness, patients need to receive ongoing bisphosphonate or Prolia therapy after discontinuing Evenity, Forteo or Tymlos treatment.

Dr. Yong H. Tsai is board-certified in rheumatology, allergy and clinical immunology and has been practicing in this area since 1993. His website is arthritis-allergy.net.

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