PAIN MANAGEMENT: Osteoporosis treatment and increase bone mass

April 15--Our bones contain two different cell groups that, when working as a team, keep bones healthy. One cell group includes osteoclasts that break down bone, creating microscopic pits in the bone surface. The other group includes osteoblasts that form new bone to fill these holes.

This process of bone formation and absorption, called "bone remodeling," preserves throughout our life. However, when the "clasts" beat the "blasts," bone density decreases, potentially causing osteoporosis and related fractures.

Women in their 40s lose about 1 percent of bone mass from their spine per year. During menopause, this rate increases to 3 percent or more. After menopause, decreased estrogen leads to increased RANK ligand and increased osteoclast activity. RANK ligand is an essential mediator of osteoclast activity.

Bisphosphnates 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 indicated for patients with a history of osteoporosis-related fracture or multiple risk factors for fractures or fail other available osteoporosis therapy or intolerable to other osteoporosis therapy. Prolia is administered subcutaneously by a healthcare professional every six months.

Prolia and Fosamax can suppress bone turnover and remodeling by inhibiting osteoclast activity. The consequence of long term suppression of bone turnover is not clear at this point. Cases with unusual fractures or delayed fracture healing or osteonecrosis of the jaw are occasionally reported in patients with prolonged treatment of bisphosphonates. Except for people with a significantly high fracture risk, most patients, after five-year bisphosphonate treatment, may consider discontinuing bisphosphonate treatment (bisphosphonate holiday) for two years.

Final medications to consider are Forteo (teriparatide) and Tymlos (abaloparatide) are synthetic forms of parathyroid hormone. Those drug simulate the biologic effects of our parathyroid gland. Unlike other available therapies for osteoporosis, Forteo and Tymlos work by stimulating osteoblasts and enhancing new bone growth, as opposed to just preventing further bone loss.

Forteo and Tymlos work much quicker and more effectively at increasing bone production in the spine and hips than anti-absorptive drugs, yet they are more expensive than other anti-osteoporosis drugs and must be administered daily.

Currently, those medications are recommended for patients with severe osteoporosis, a history of osteoporotic fracture, and an inability to tolerate bisphosphonate therapy.

Forteo and Tymlos therapy are restricted to two years, and it is important to note that the beneficial effects quickly diminish after discontinuing treatment.

To maintain the benefits and maximize effectiveness, patients need to receive ongoing bisphosphonate or Prolia therapy after discontinuing Forteo or Tymlos treatment.

Thanks to recent advances in medicine, osteoporosis patients have a variety of medication choices capable of increasing bone mass and improving overall bone quality.

-- 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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