Using sequential pharmacotherapy for the treatment of osteoporosis: an update of the literature

ABSTRACT

Introduction

Osteoporosis, which is characterized by compromised bone density and heightened susceptibility to fractures, is a substantial public health concern, especially among the aging population. Underdiagnosis, undertreatment, and therapy non-adherence contribute to its impact. Anabolic and dual-action agents like teriparatide, abaloparatide, and romosozumab have emerged as effective treatments, allowing rapid gains in bone mineral density (BMD) and reducing fracture risk. However, administering treatments in the correct order is paramount, with an ‘anabolic first’ approach gaining traction for patients at high risk of fractures. This strategy involves starting anabolic therapies, followed by antiresorptive agents as maintenance therapy. It is important to note that the effectiveness of anabolic agents differs between treatment-naive and previously treated patients: tailored treatment approaches are therefore necessary. This comprehensive strategy adheres to clinical guidelines, emphasizing individualized care, early intervention, and patient-centered management to mitigate the burden of osteoporosis and enhance patients’ quality of life.

Area covered

The aim of this review is to summarize recent evidence on the sequential treatment of osteoporosis and to provide recommendations on the best treatment strategies.

Expert opinion

Effective treatments, such as anabolic agents, are key in high-risk patients, who require an ‘anabolic first’ approach. Sequential therapy, specifically tailored to a patient’s history, can help to optimize prevention and management of fractures.

KEYWORDS:

• Anabolic agents
• dual-action agent
• high risk of fracture
• osteoporosis
• sequential treatment

Article highlights

• Anabolic and dual action agents, such as teriparatide, abaloparatide and romosozumab, constitute the new frontier in osteoporosis treatment as they allow rapid gains in bone mineral density (BMD), dramatically reducing the risk of fracture.

• Current international guidelines support an ‘anabolic first’ approach for patients considered at very high risk of fracture.

• As anabolic drugs can only be prescribed for a limited period, maintenance treatment with antiresorptive agents is recommended.

• Although anabolic and dual-action agents are often prescribed as second line agents after antiresorptive treatment failure, their effectiveness is greater in naïve patients: this evidence will lead to changes in clinical practice in the near future.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Acknowledgments

We would like to express our gratitude to Dr Victoria Ando for her help in the revision of the grammar and syntaxis of this paper.

Reviewer disclosures

A reviewer on this manuscript has been recruited by Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.

Additional information

Funding

This paper was not funded.