Osteoporosis for Rheumatologists: Latest Updates and Controversies

While many agents now exist for osteoporosis treatment, their clinical use is attenuated my questions about comparative effectiveness and safety. Calcium and Vitamin D are essential for optimal bone health and may have other health benefits but excessive supplemental doses, in the absence of deficiencies, may be deleterious. Greatest interest has been directed to rare occurrences of osteonecrosis of the jaw and atypical femoral fractures associated with bisphosphonates and denosumab. These potential adverse effects may be offset by selective use of a bisphosphonate “drug holiday”. On the other hand, denosumab discontinuation leads to rapid bone loss and a heightened risk of fracture, necessitating an “exit strategy.” Teriparatide may have comparatively greater efficacy than other drugs in high risk patients. Romosozumab, while highly efficacious in comparator studies with bisphosphonates, has shown a controversial increase in cardiovascular adverse outcomes. Data is emerging on novel osteoanabolics and their regulatory approval will be aided by surrogate endpoints. Using incidental CT scans and other newer technologies will help detect more at risk patients sooner. Despite the potential for mostly rare adverse effects, for the vast majority of patients the benefits of osteoporosis therapy far outweigh their risks.