علاج هشاشة العظام مع خطر كسر مرتفع جداً

References

• Features include multiple vertebral fractures, T-score ≤−3.0 to −3.5, a recent fragility fracture within the previous one to two years, high dose glucocorticoids >7.5 mg/day of prednisolone or equivalent over three months, or FRAX for MOF >30% or hip fracture >4.5% (table 2).
• All recommend anti-resorptives as first line therapy for patients at high risk and osteoanabolics for those at very high risk.
• Osteoanabolic agents preferred first line for people at very high risk: teriparatide, abaloparatide, romosozumab.
• For patients at very high risk, teriparatide, abaloparatide, or romosozumab is recommended first line in all guidelines.
• An osteoanabolic-first approach seems to be the most effective strategy in people at very high risk, rather than an osteoanabolic agent being considered as second or third line treatment after other therapies have failed.
• For postmenopausal women and older men, aim for total elemental calcium 1000–1200 mg/day and vitamin D 800–1000 IU/day.
• In people at higher risk, such as older people with history of previous fracture, a higher target of −2.0 to −1.5 might be advisable, as supported by evidence from the FREEDOM (denosumab) and ARCH (romosozumab, alendronate) trials, as well as robust meta-regression data showing continued reduction in fracture risk up to a T-score of −1.5 at the total hip.
• Experts recommend an improvement in total hip T-score of at least 0.2 units (3%) and in lumbar spine T-score of at least 0.5 units (6%), on the basis of reasonable chances of attaining such increments over three years by most therapies, including anti-resorptives.
• BMD every 1–3 years on therapy.