Ian Reid is an endocrinologist and Distinguished Professor at the University of Auckland, where he is Deputy Dean of the Faculty of Medical and Health Sciences. His research interests include calcium metabolism, vitamin D and osteoporosis. He is a past-president of the International Bone and Mineral Society (IBMS), and a recipient of research awards nationally and internationally, including the New Zealand Prime Minister’s Science Prize.
Managing Osteoporosis In 2019
The progressive increases in longevity around the world seem set to continue, bringing with them a steady rise in the burden of fractures. Strategies for targeting treatment to prevent these fractures are also likely to evolve. Refinements to the existing fracture calculators will continue, however, if treatments that are affordable can be demonstrated to broadly effective in fracture prevention in older individuals, the importance of precise targeting of treatments might diminish in the foreseeable future. Falls prevention is a key part of fracture prevention.
The use of calcium supplements is likely to diminish as the evidence for their lack of efficacy and safety becomes more widely accepted. Vitamin D deficiency remains common in the elderly, use of 400-1000 IU/day (or equivalent) is important in those at risk, based on clinical assessment. The bisphosphonates are an inexpensive and effective way of reducing fracture numbers, but clarification of their safety and a broader acceptance of this are important next steps. Renal impairment is more common with increasing age, and is a relative contraindication to oral bisphosphonate, and an absolute contraindication to intravenous bisphosphonates. Denosumab is an effective treatment which is well tolerated, even with renal impairment, but recognition of its rapid offset and the institution of strategies to address that need to be put in place. Teriparatide is currently restricted with respect to duration of use, but this needs to be critically evaluated. Are longer courses of treatment more effective for fracture prevention, and do repeated courses have long term benefits? Cost and the apparent need for daily injections also limit its use.
Many drugs prevent fractures in patients with osteoporosis, but their efficacy in women with osteopenia is unknown. Most fractures in postmenopausal women occur in osteopenic individuals, so if pharmaceutical intervention is to impact significantly on total fracture numbers, therapies with efficacy in osteopenic postmenopausal women are needed. We have recently reported that zoledronate prevents fractures in women >65 years of age, and also reduces cancer and myocardial infarction risk. This suggests that a broader use of this agent is justified.
While anabolics will be important for restoring bone mass, anti-resorptives are likely to be the mainstay of future endeavours to prevent fractures in the elderly.