Traitement de l'ostéoporose avec fracture pathologique : fractures vertébrales multiples ou densité minérale osseuse très basse

References

DOI: 10.1136/bmj‐2024-081250

• 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%.
• For patients at very high risk, teriparatide, abaloparatide, or romosozumab is recommended first line in all guidelines.
• The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) guideline supports an osteoanabolic-first approach for patients at very high risk of fracture.
• 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 and ARCH 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.
• On teriparatide or abaloparatide, aim for P1NP above reference range or change greater than LSC.
• On anti-resorptives, aim for suppression of P1NP and CTX below mean/median of healthy adult or change greater than LSC.
• The National Academy of Medicine recommends a target 25-hydroxyvitamin D concentration of 20 ng/mL, whereas other guidelines suggest 30 ng/mL for older adults and at-risk populations.