Table Of ContentThe Duration and
Safety of Osteoporosis
Treatment
Anabolic and
Antiresorptive Therapy
Stuart L. Silverman
Bo Abrahamsen
Editors
123
The Duration and Safety of Osteoporosis
Treatment
Stuart L. Silverman (cid:129) Bo Abrahamsen
Editors
The Duration and Safety
of Osteoporosis
Treatment
Anabolic and Antiresorptive Therapy
Editors
Stuart L. Silverman, MD, FACP, FACR Bo Abrahamsen, MD, PhD
Cedars-Sinai Medical Center University of Southern Denmark
Division of Rheumatology Odense Patient Data Explorative
Department of Medicine Network
Los Angeles , CA , USA Institute of Clinical Research
Odense , Denmark
University of California Los Angeles
David Geffen School of Medicine Holbæk Hospital
Los Angeles, CA, USA Department of Medicine
Holbæk, Denmark
ISBN 978-3-319-23638-4 ISBN 978-3-319-23639-1 (eBook)
DOI 10.1007/978-3-319-23639-1
Library of Congress Control Number: 2015957990
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Foreword
Advances in the management of osteoporosis in the last two to three decades
have exceeded that of most other chronic diseases of aging, yet suboptimal
rates of treatment are widely reported. These arise partly from underrecogni-
tion of osteoporosis as a disease but also from concerns about the safety of
treatment and the related issue of for how long treatment should be given.
Rare but serious side effects such as atypical femoral fractures and osteone-
crosis of the jaw have received much attention in the media and have made
many patients and their doctors reluctant to embark on or continue therapy. In
addition, the evidence base on which to develop advice about duration of
therapy is incomplete. Despite these diffi culties, however, there is consensus
in the fi eld that when appropriately targeted, the benefi ts of treatment out-
weigh the risks. In addition, there is increasing agreement that after 3–5 years
treatment with the most commonly used intervention, bisphosphonate ther-
apy, it may be possible to stop treatment for a limited period of time in some
people, although in those at high risk of fracture, long-term continuous ther-
apy is often required.
In their book “The Safety and Duration of Osteoporosis Treatment,” Stuart
Silverman and Bo Abrahamsen address these diffi cult and critical issues
against a background of the epidemiology and pathophysiology of osteoporo-
sis, approaches to the assessment of fracture risk, and the effi cacy and safety
of pharmacological interventions to reduce fracture risk. Detailed coverage is
given to the epidemiology, diagnosis, clinical presentation, and management
of atypical femoral fractures and osteonecrosis of the jaw. The controversial
topic of treatment failure is discussed, and approaches to improving adher-
ence to therapy are considered. Potential nonskeletal benefi ts of treatments
and effects of therapy on fracture healing are included and regulatory per-
spectives are covered. The closing chapter of the book presents an integrated
approach to the long-term management of osteoporosis in the light of what is
known about effi cacy and safety of existing interventions.
This book, edited and written by leading experts in the fi eld, provides a
welcome update on some of the most topical but challenging issues in the
management of osteoporosis. While many gaps in knowledge remain, there
have also been advances that allow more accurate assessment of the balance
of risk and benefi t in individual patients. For healthcare professionals involved
in the care of osteoporosis, this book offers a balanced perspective that will
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vi Foreword
aid decision making about when to start treatment, how long to continue it,
and how to ensure that patients understand the safety issues involved. It also
provides a glimpse of the future, with treatment individualized according to
the specifi c disease characteristics and preferences of the patient to achieve
optimal effi cacy, safety, and adherence.
Cambridge Biomedical Campus J uliet Compston, MBBS, MD,
Addenbrooke’s Hospital FRCP, FRCPath, FMedSci
Cambridge , UK
Pref ace
In the past three decades, clinicians treating osteoporosis have seen the dis-
ease change from being a debilitating chronic disease with few treatment
options and little chance of real improvement. However, with the introduction
of the bisphosphonates and later the SERMs, parathyroid hormone-based
anabolics, and more recently the biologicals, our viewpoint has changed
enormously. Unlike other chronic diseases such as hypertension or asthma
where we try to stabilize the condition, in osteoporosis we have the promise
of improving skeletal health, increasing bone mineral density, and reducing
risk of fracture. However, how much do we really know about the long-term
management of osteoporosis in the current era of potent antiresorptive and
anabolic medications? The mainstay of osteoporosis treatment remains the
affordable bisphosphonates. However, from the initial introduction of
bisphosphonates, the fi rst antiresorptive drugs, there was the nagging doubt
that they were almost too good to be true. Surely we will have developed
bone remodeling for a reason. For how long can we safely put a dampener on
bone resorption without some cost in the form of accumulation of old bone
tissue of potentially poorer strength and increased brittleness?
Patients, clinicians, specialty societies, and health authorities are legiti-
mately concerned about side effects of osteoporosis medications, both short
and long term. Though still rare, atypical femur fractures and osteonecrosis
of the jaw are legitimate concerns and the time has certainly come to collect
the scientifi c information on the safety and duration of osteoporosis therapies
that is currently available and to digest and interpret it.
A s Editors we asked top scientists and clinicians in the bone fi eld to review
and update the reader on the pathophysiology of osteoporosis and the prin-
ciples behind our present and future drugs for osteoporosis, both antiresorp-
tive and anabolic. This book contains a comprehensive compendium of
short- and long-term adverse events that have been suspected or demonstrated
for osteoporosis drugs. We asked for chapters covering prediction of fracture
risk, monitoring of response to treatment, and identifi cation of treatment fail-
ure. The practical management of drug holidays and tools for improving
adherence are comprehensively dealt with in the subsequent chapters.
We hope this book will give clinicians a practical compendium of evi-
dence that will allow them to continue to make the best informed decisions
together with their patients about important decisions including when to
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viii Preface
modify, stop, or reinitiate osteoporosis treatment. The book is also intended
to facilitate the work of health planners and regulatory authorities and help
researchers and funding bodies set the future research agenda for manage-
ment of osteoporosis.
Los Angeles, CA, USA Stuart L. Silverman, MD, FACP, FACR
Odense, Denmark Bo Abrahamsen, MD, PhD
Acknowledgment
The coeditors (Stuart L. Silverman and Bo Abrahamsen) both wish to
acknowledge the importance of mentorship by colleagues during their journey
in Bone disease.
S tuart L. Silverman would like to acknowledge the late Louis Avioli who
encouraged him to study clinical bone disease and the late Moise Azria with
whom he spent years together traveling and debating the safety of osteoporosis
therapies.
Bo Abrahamsen would like to acknowledge his mentor, the late Sandy
Marks, Jr., from UMASS Medical Centre, Erik Eriksen his PhD supervisor,
and Richard Eastell who introduced him to atypical femur fractures and to
how to set up an integrated osteoporosis service.
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