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Osteoporose: Behandlung von Hochrisikopatient*innen

Osteoporosis: treatment of high-risk patients

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Zusammenfassung

Zur spezifischen medikamentösen Therapie der Osteoporose stehen Antiresorptiva (Raloxifen, Bisphosphonate, Denosumab) und Osteoanabolika (Teriparatid und Romosozumab) zur Verfügung. Für beide Osteoanabolika konnte in randomisierten Vergleichsstudien eine Überlegenheit gegenüber oralen Bisphosphonaten bei Hochrisikopatient*innen gezeigt werden. Hochrisikopatient*innen stellen eine Untergruppe der behandlungsbedürftigen Osteoporosepatient*innen mit besonders hohem Frakturrisiko dar. Das sehr hohe Risiko ist an der Klinik (Femur- oder Wirbelkörperfraktur), dem sehr niedrigen T‑Score und/oder den klinischen Risikofaktoren (Überschreitung der osteoanabolen Schwelle des DVO-Risikorechners) zu erkennen. Hochrisikopatient*innen sollten in erster Therapielinie mit Osteoanabolika behandelt werden. Antiresorptiv vorbehandelte Patient*innen, die erst im Verlauf ein sehr hohes Risiko entwickeln, sollten auf Osteoanabolika eskaliert werden. Jede osteoanabole Therapie erfordert eine antiresorptive Anschlusstherapie. Therapiepausen sind bei Hochrisikopatient*innen nur in Ausnahmefällen möglich.

Abstract

Nowadays, different drugs are available for specific treatment of osteoporosis. On the one hand, antiresorptives (raloxifene, bisphosphonates, denosumab) and, on the other hand, bone anabolic drugs (teriparatide and romosozumab) can be used. For both bone anabolic agents, superiority over oral bisphosphonates in high-risk patients was shown in randomized comparative studies. High-risk patients represent a subgroup of osteoporosis patients requiring treatment with a particularly high fracture risk. The very high risk can be recognized by the clinical manifestation (hip or vertebral fracture), the very low T‑score and/or the clinical risk factors (exceeding the bone anabolic threshold of the DVO risk calculator). High-risk patients should be treated with bone anabolic drugs in the first line of treatment. Patients treated with antiresorptives, who develop a very high risk in the course of the disease should be escalated to bone anabolic compounds. Every bone anabolic treatment requires an antiresorptive follow-up treatment. Drug holidays are only possible in exceptional cases for high-risk patients.

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Abbreviations

AACE:

American Association of Clinical Endocrinology

ACE:

American College of Endocrinology

AFF:

Atypische Femurfrakturen

ARCH:

Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk

BHOF:

Bone Health and Osteoporosis Foundation

BMI:

Body-Mass-Index

CKD:

„Chronic kidney disease“

DVO:

Dachverband Osteologie

DXA:

Dual-Röntgen-Absorptiometrie

ESCEO:

European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases

FRAX:

Fracture Risk Assessment Tool

GFR:

Glomeruläre Filtrationsrate

IOF:

International Osteoporosis Foundation

iPTH:

Intaktes Parathormon

LWS:

Lendenwirbelsäule

MOF:

„Major osteoporotic fractures“

NOGG:

National Osteoporosis Guideline Group

ONJ:

Kieferknochennekrosen

RR:

Relatives Risiko

SERM:

Selektive Östrogenrezeptormodulatoren

SIGN:

Scottish Intercollegiate Guidelines Network

SVGO:

Schweizerische Vereinigung gegen Osteoporose

VERO:

VERtebral fracture treatment comparisons in Osteoporotic women

WHO:

World Health Organization

WK#:

Wirbelkörperfraktur, Graduierung nach Genant

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  1. LMU Klinikum, Osteologisches Schwerpunktzentrum der LMU – Bayerisches Osteoporosezentrum, Medizinische Klinik und Poliklinik IV, Ziemssenstr. 5, 80336, München, Deutschland

    Ralf Schmidmaier

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R. Schmidmaier erhielt Vortragshonorare von Amgen, Lilly und UCB, sowie Beraterhonorare von Amgen.

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Schmidmaier, R. Osteoporose: Behandlung von Hochrisikopatient*innen. Orthopädie 52, 799–807 (2023). https://doi.org/10.1007/s00132-023-04430-1

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