Goal-directed treatment of osteoporosis in Europe
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Despite the proven predictive ability of bone mineral density, Fracture Risk Assessment Tool (FRAX®), bone turnover markers, and fracture for osteoporotic fracture, their use as targets for treatment of osteoporosis is limited.
Treat-to-target is a strategy applied in several fields of medicine and has recently become an area of interest in the management of osteoporosis. Its role in this setting remains controversial. This article was prepared following a European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) working group meeting convened under the auspices of the International Osteoporosis Foundation (IOF) to discuss the feasibility of applying such a strategy in osteoporosis in Europe.
Potential targets range from the absence of an incident fracture to fixed levels of bone mineral density (BMD), a desired FRAX® score, a specified level of bone turnover markers or indeed changes in any one or a combination of these parameters.
Despite the proven predictive ability of all of these variables for fracture (particularly BMD and FRAX), their use as targets remains limited due to low sensitivity, the influence of confounders and current lack of evidence that targets can be consistently reached.
ESCEO considers that it is not currently feasible to apply a treat-to-target strategy in osteoporosis, though it did identify a need to continue to improve the targeting of treatment to those at higher risk (target-to-treat strategy) and a number of issues for the research agenda. These include international consensus on intervention thresholds and definition of treatment failure, further exploration of the relationship between fracture and BMD, and FRAX and treatment efficacy and investigation of the potential of short-term targets to improve adherence.
KeywordsBMD Bone marker FRAX Management strategy Osteoporosis Target-to-treat Treat-to-target
We are grateful to the Committee of Scientific Advisors of the International Osteoporosis Foundation and the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis for their review and endorsement of this paper.
Conflicts of interest
JA Kanis has received consulting fees, advisory board fees, lecture fees and/or grant support from the majority of companies concerned with skeletal metabolism. E McCloskey has received consultancy, lecture fees, research grant support and/or honoraria from Active Signal, Alliance for Better Bone Health, Amgen, Bayer, Consilient Healthcare, GE Lunar, Hologic, Internis Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Servier, Tethys, UCB and Univadis. ML Brandi has received consulting fees, paid advisory boards, lecture fees and/or grant support from Amgen, Eli Lilly, Merck Sharp & Dohme, Novartis, Servier, Spa, Stroder and NPS. E Dennison declares lecture fees from Lilly. S Ferrari has received consulting fees, advisory board fees, lecture fees and/or grant support from Amgen, GSK, MSD, Eli Lilly, Novartis and Bioiberica. J-M Kauffman has received consulting fees, paid advisory boards, lecture fees and/or grant support from Amgen, Eli Lilly, GlaxoSmithKline, Merck, Novartis, Procter & Gamble, Roche, Sanofi Aventis, Servier and Warner Chilcott. S Papapoulos has received consulting/speaking fees from Axsome, Amgen, Eli Lilly, GlaxoSmithKlein, Merck, Novartis and Roche. J-Y Reginster on behalf of the Department of Public Health, Epidemiology and Health Economics of the University of Liège, Liège, Belgium, received consulting fees or paid advisory boards from Servier, Novartis, Negma, Lilly, Wyeth, Amgen, GlaxoSmithKline, Roche, Merckle, Nycomed, NPS, Theramex, UCB. Lecture fees when speaking at the invitation of a commercial sponsor: Merck Sharp and Dohme, Lilly, Rottapharm, IBSA, Genevrier, Novartis, Servier, Roche, GlaxoSmithKline, Teijin, Teva, Ebewee Pharma, Zodiac, Analis, Theramex, Nycomed, Novo-Nordisk. R Rizzoli received lecture fee and paid advisory boards from Merck Sharp and Dohme, Eli Lilly, Amgen, Servier, Takeda and Danone. JC Branco and JP Devogelaer have no conflict of interest.
- 4.(1993) Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 94:646–650Google Scholar
- 5.Kanis JA, on behalf of the World Health Organization Scientific Group (2007) Assessment of osteoporosis at the primary health care level. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK, Sheffield, Technical ReportGoogle Scholar
- 7.Mancia G, Fagard R, Narkiewicz K et al (2013) 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 34:2159–219PubMedCrossRefGoogle Scholar
- 10.Inzucchi SE, Bergenstal RM, Buse JB et al (2012) Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 55:1577–96PubMedCrossRefGoogle Scholar
- 11.IDF Clinical Guidelines Task Force (2013) Global Guideline for Type 2 Diabetes. www.idf.com. Accessed 17 July 2013
- 18.National Institute for Health and Clinical Excellence (NICE)—British Hypertension Society (BHS) (2006) Hypertension: management of hypertension in adults in primary care. www.nice.org.uk/CG034guidance. Accessed 31 July 2013
- 20.National Institute for Health and Clinical Excellence (2011) Hypertension: The clinical management of primary hypertension in adults. August 2011. http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf. Accessed 13 Jan 2012
- 21.Goff DC Jr., Lloyd-Jones DM, Bennett G et al. (2013) 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. CirculationGoogle Scholar
- 22.Stone NJ, Robinson J, Lichtenstein AH et al. (2013) 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll CardiolGoogle Scholar
- 23.Kane SP (2014) Pooled cohort equations to predict 10-year risk of first cardiovascular event. http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx. Accessed 7 April 2014
- 24.Nathan DM, Buse JB, Davidson MB et al (2009) Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 32:193–203PubMedCrossRefPubMedCentralGoogle Scholar
- 36.Ferrari S, Adachi J, Lippuner K et al (2013) Further reductions in nonvertebral fracture rate with long-term denosumab treatment in the FREEDOM open-label extension and influence of hip bone mineral density after 3 years. Abstr J Bone Miner Res 28:1017Google Scholar
- 41.Jacques RM, Boonen S, Cosman F et al (2012) Relationship of changes in total hip bone mineral density to vertebral and nonvertebral fracture risk in women with postmenopausal osteoporosis treated with once-yearly zoledronic acid 5 mg: the HORIZON-Pivotal Fracture Trial (PFT). J Bone Miner Res 27:1627–34PubMedCrossRefGoogle Scholar
- 55.Bergmann P, Body JJ, Boonen S et al (2009) Evidence-based guidelines for the use of biochemical markers of bone turnover in the selection and monitoring of bisphosphonate treatment in osteoporosis: a consensus document of the Belgian Bone Club. Int J Clin Pract 63:19–26PubMedCrossRefPubMedCentralGoogle Scholar
- 63.Bala Y, Zebaze R, Ghasem-Zadeh A et al. (2014) Cortical porosity identifies women with osteopenia at increased risk for forearm fractures. J Bone Miner ResGoogle Scholar
- 78.Hernlund E, Svedbom A, Ivergard M et al (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden: a report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136PubMedCrossRefPubMedCentralGoogle Scholar
- 80.Solomon DH, Johnston SS, Boytsov NN et al. (2014) Osteoporosis medication use after hip fracture in U.S. Patients between 2002 and 2011. J Bone Miner ResGoogle Scholar