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What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis?

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Abstract

Pharmacologic osteoporosis therapy, particularly anti-resorptives, is recommended in postmenopausal women with clinical risk factors for fracture. Treatment decisions should be made based on the relative benefit–risk profile in different patient populations. Emerging options [e.g., selective estrogen receptor modulators (SERMs) and denosumab] may hold promise for providing protection from bone loss and for fracture risk reduction.

Osteoporosis, the most common clinical disorder of bone metabolism, is characterized by low bone mineral density, deterioration of microarchitecture, and a consequent increase in bone fragility and risk of fracture. Pharmacologic therapy is recommended in postmenopausal women with clinical risk factors for fracture and includes anti-resorptive agents such as bisphosphonates, hormone therapy, SERMs, and calcitonin. The anabolic agent teriparatide (parathyroid hormone) is usually reserved for high-risk patients or those with glucocorticoid-induced osteoporosis. Strontium ranelate, available outside the USA, has both anti-resorptive and anabolic properties. Supplementation with calcium and vitamin D is recommended for all women aged 50 years and older. Bisphosphonates are often considered first-line therapy for osteoporosis and have the largest base of clinical trial data showing efficacy for global fracture risk reduction. Low-dose hormone therapy is appropriate for younger women who are experiencing other menopausal symptoms. In women for whom bisphosphonates are not appropriate or not tolerated or in younger postmenopausal women who have a low risk for hip fracture, SERMs are a suitable treatment option. Calcitonin is designated for patients who are unable or unwilling to tolerate other osteoporosis agents. Emerging options, including newer SERMs (e.g., bazedoxifene and lasofoxifene) and the monoclonal antibody denosumab, may hold promise for providing protection from bone loss and for fracture risk reduction. Because no single agent is appropriate for all patients, treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.

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Acknowledgments

Editorial support for the writing of this manuscript was provided by Bo Choi, PhD, and was funded by Wyeth Research, Collegeville, PA, which was acquired by Pfizer Inc in October 2009. The authors were not compensated and retained full editorial control over the content of the manuscript.

Conflicts of interest

Dr. Miller has received scientific grants from Procter & Gamble, Sanofi-Aventis, Roche, Eli Lilly, Merck, Novartis, and Amgen; he has served on speaker/advisory boards and been a consultant for Procter & Gamble, Sanofi-Aventis, Merck, Eli Lilly, Amgen, NPS, Novartis, Roche, and GlaxoSmithKline. Dr. Derman reports no conflicts of interest.

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  1. Colorado Center for Bone Research, 3190 South Wadsworth Blvd, Lakewood, CO, 80227, USA

    P. D. Miller

  2. Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, DE, USA

    R. J. Derman

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Correspondence to P. D. Miller.

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Miller, P.D., Derman, R.J. What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis?. Osteoporos Int 21, 1793–1802 (2010). https://doi.org/10.1007/s00198-010-1208-3

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