Treatment Sequence Matters in Osteoporosis


Osteoporosis therapeutic treatments should always be individualized, says Felicia Cosman, M.D., an endocrinologist with Columbia University College of Physicians and Surgeons in New York. Dr. Cosman is the author of a study recently presented at the American College of Rheumatology annual meeting in which she shared results from a study that explored treatment sequences with romosozumab before or after antiresorptive medication.

Patients are different, she explains. From a difference in age to disease severity and disease stage, the treatment course should be individualized, she said.

"We've known for a long time that antiresorptive and anabolic agents work by different mechanisms. Most of the medicines that we use for osteoporosis are indeed antiresorptive agents beginning in the 2000s. We have the anabolic medication, teriparatide (Forteo, Eli Lilly), then two new anabolic medications came on the market recently:abaloparatide (Tymlos, Radius Health) in 2017 and romosozumab (Evenity, Amgen) in 2019," Dr. Cosman says.

"Most of the work that has been done has involved teriparatide. We've learned over the last five or so years that---with teriparatide---the sequence of treatment matters. We get a better benefit to bone mass and bone density when teriparatide is given first and the antiresorptive medications are given in sequence afterward, but with the new medication romosozumab, it works by a very different mechanism of action than teriparatide and abaloparatide. So, we wonder whether the romosozumab treatment sequence would also be as important as it is for teriparatide. In order to evaluate this question, we reviewd four studies:two of them used the romosozumab first---those were the ARCH and FRAME trials---which are two big fracture end point studies. And, two used tomosozumab after the antiresorptive medication (the STRUCTURE and the phase two study extension studies).

"The findings showed that indeed treatment sequence is also important with romosozumab The effects on both hip bone density and spine density were both larger when romosozumab was used as the initial therapy and the antiresorptive afterwards," she said.

Learn more in this interview with Dr. Cosman.



American College of Rheumatology 2020 annual meeting, abstract Abstract Number 1973: "Treatment Sequences with Romosozumab Before or After Antiresorptive Medication."

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