Osteoporosis at Very High Risk of Fracture: What to Do When Osteoanabolic Therapy Has Not Reached T-score Targets
This protocol addresses the sequential next step for patients with osteoporosis at very high fracture risk who have completed an osteoanabolic treatment course but have not achieved the defined bone mineral density targets.
Very high fracture risk is defined by one or more of the following: multiple vertebral fractures; bone mineral density T-score ≤−3.0 to −3.5; a fragility fracture within the previous one to two years; high-dose glucocorticoids (>7.5 mg/day prednisolone or equivalent for three months or more); a FRAX 10-year major osteoporotic fracture probability >30%; or a FRAX 10-year hip fracture probability >4.5%.
The prior line was osteoanabolic-first therapy with teriparatide, abaloparatide, or romosozumab. The goals that triggered escalation to this protocol are: failure to reach the personalised total hip T-score target (−2.0 to −1.5 in very-high-risk patients), with 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%) over three years.
The approach involves a sequential transition to an anti-resorptive agent to consolidate and further extend the BMD gains achieved — one agent class is preferred over others, with evidence supporting substantially greater continued gains for specific transition sequences.
Clinical goal: Continued increase in total hip, femoral neck, and lumbar spine BMD, consolidating the gains achieved with osteoanabolic therapy.
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% (table 2).
All recommend anti-resorptives as first line therapy for patients at high risk and osteoanabolics for those at very high risk.
Evidence suggests that starting with an osteoanabolic agent followed by an anti-resorptive agent provides optimal BMD gains (fig 3).
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.
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