New drugs for osteoporosis

Editor, – I read ‘New drugs for osteoporosis’ by Peter Ebeling with interest ( Aust Prescr 2011;34:176-81 ). I must compliment him on a lucid, comprehensive and informative article about a very common disease. The comparative table about the new drugs gives almost all the information at a glance. I understand that these drugs are to be given when usual treatment is ineffective. However, I have a few questions to ask the author:

1. 1. Which is the drug of first choice amongst the new drugs, especially in refractory cases?
2. 2. In some countries or ethnicities menopause starts early. Does the line of management change?
3. 3. For therapeutic menopause, which invariably is earlier than usual, what should be the management since oestrogen is missing and replacement therapy is contraindicated?

Jyoti Yadav
Professor of Physiology
Pt BD Sharma Post Graduate Institute of Medical Sciences
Haryana, India

Peter Ebeling, author of the article, comments:

I would like to thank Professor Yadav for her thoughtful questions. In response, I would say that in Australia three of the four osteoporosis medications mentioned in my article are first-line treatments for osteoporosis – zoledronic acid, denosumab and strontium ranelate. They are all used as alternative options to the other first-line treatments – oral bisphosphonates or raloxifene. However in patients with severe osteoporosis, teriparatide is used when fractures occur after 12 months of therapy with other medications or when intolerance to these medications occurs.

In answer to question 1, if fractures have occurred on oral bisphosphonates it could be because the medications have been taken incorrectly or they are ineffective in patients with severe osteoporosis. If compliance or correct dosing is thought to be the main issue, parenteral therapy with either zoledronic acid or denosumab would be best. However, if the treatment was truly ineffective, teriparatide would be a better option for patients with severe osteoporosis.

In answer to question 2 about early menopause, most specialists would reserve treatment with these drugs until later in life when the absolute fracture risk is higher (calculated using the FRAX or Garvan Institute tools). However if the absolute fracture risk was already high, all would be options for treatment with the exception of teriparatide.

With therapeutic menopause (question 3), it would depend on whether the absolute fracture risk was elevated. Oral or intravenous bisphosphonates, denosumab or strontium ranelate could all potentially be used to prevent bone loss in these younger postmenopausal women.