Clinical Review

UPDATE ON OSTEOPOROSIS

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When the models that included BUA were compared with those that used femoral neck BMD, they had a greater area under the curve (0.71, 0.85, 0.71 for any fracture, hip fracture, and vertebral fracture, respectively) and yielded a net reclassification improvement of 16.4% (P=.009) when combined with femoral neck BMD. These findings suggest that calcaneal BUA is an independent predictor of fracture risk in women who have nonosteoporotic BMD.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

In an era of increasing pressure to reduce costs, QUS assessment of bone is a promising modality that may be useful as a screening tool. Although it measures different variables than DXA imaging (more microarchitecture, less true density), it seems to predict the risk of fracture at less cost without ionizing radiation.

In the pipeline: A drug that curbs bone resorption without diminishing bone formation

Williams SC. Potential first-in-class osteoporosis drug speeds through trials. Nat Med. 2012;18(8):1158.

Ng KW. Potential role of odanacatib in the treatment of osteoporosis. Clin Interv Aging. 2012;7:235–247.

Alendronate was the first of the oral bisphosphonates to be approved by the US Food and Drug Administration (FDA). Once it was approved in 1999, the drug quickly became the most widely used bone agent in clinical practice and was soon joined by other oral and intravenous bisphosphonates. Regrettably, highly publicized adverse effects have caused many patients to shy away from this class of drugs. Two years ago, the FDA approved denosumab, a subcutaneous injectable agent that is a RANK ligand inhibitor.

The bisphosphonates and denosumab increase bone mass by shutting down the osteoclasts responsible for bone resorption, but they also inhibit creation of new bone. A new category of drug that inhibits the bone-resorption enzyme Cathepsin K appears to inhibit bone resorption without diminishing bone formation. Trials of two previous agents in this class were halted because of adverse effects—particularly effects to the skin, where the enzyme is expressed in addition to bone. However, Phase 2 trials in which odanacatib was compared with alendronate found that the new drug increased BMD almost twice as much as alendronate did, with less reduction in serum markers of bone formation.

Phase 3 trials of odanacatib in 16,000 women older than age 65 recently were halted so that the manufacturer could pursue regulatory approval ahead of the previous schedule. Although Phase 3 data have not been published yet, odanacatib may prove to be an exciting alternative to existing therapies.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Odanacatib is not yet available. However, by discussing therapies that may be “around the corner” with our patients, we demonstrate that we are staying ahead of the curve of scientific development.

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