Goal-Directed Treatment for Osteoporosis: A Progress Report

The American Society for Bone and Mineral Research (ASBMR) and the United States National Osteoporosis Foundation (NOF) have joined forces to ramp up osteoporosis care, establishing a working group to tackle goal-setting for treatment decisions.

In the paper, entitled, “Goal-Directed Treatment for Osteoporosis: A Progress Report From the ASBMR-NOF Working Group on Goal-Directed Treatment for Osteoporosis,” the authors write, “With current guidelines for managing osteoporosis, once a decision has been made to treat a patient with a pharmacologic agent, a “first-line” drug, usually an oral bisphosphonate, is prescribed. BMD [bone mineral density] is often repeated 1 to 2 years later to evaluate for response to therapy. Stabilization or improvement of BMD is usually accepted as validation that the patient is responding appropriately to treatment. The same treatment is then continued; after 3 to 5 years of oral or intravenous bisphosphonate therapy, a bisphosphonate “holiday” may be considered…”

Goal-directed treatment, however, aims for “freedom from fracture (or at least a low risk of fracture),” say the authors. “In contrast, goal-directed treatment is a strategy where 1) a goal of treatment is established for a patient; 2) the initial choice of treatment is based on the probability of reaching the goal; and 3) progress toward reaching the patient’s goal is reassessed periodically, with decisions to stop, continue, or change treatment based on achievement of the goal or progress toward achievement of the goal.”

The authors indicate that this approach includes assessment for occurrence of new vertebral fracture, the occurrence of non-vertebral fracture during treatment, change in other risk factors for fracture risk on treatment, and the achievement of a T-score goal.

Steven R. Cummings, M.D is Professor Emeritus in the Department of Medicine at the University of California San Francisco. Dr. Cummings, a co-author on the study, told OTW, “We studied this because we are concerned that many patients who have a very high risk of fracture are not getting the most effective treatments but weaker ‘first line’ oral bisphosphonates. The report indicates that treatment for osteoporosis should be offered to patients based on their risk and goals for achieving life with a very low risk of fracture.”

“Insurance and health plans require using first line unless or until the patient ‘fails’ but it can be predicted by BMD and fracture risk whether patients will achieve a BMD that is no longer osteoporotic or an acceptably low risk while taking alendronate. Many high risk patients won’t achieve those goals and that is predictable in advance and they should start something stronger.”