E Michael Lewiecki, MD: Controversies in Osteoporosis

Rheumatology Network sat down with E Michael Lewiecki, MD to discuss his CCR West presentations entitled, “Controversies in Osteoporosis” and “What's New in Osteoporosis for 2021?” Lewiecki is Director at the New Mexico Clinical Research and Osteoporosis Center. We deep dive into recent controversies and trends in osteoporosis management, predictions for 2022, and how COVID-19 had impacted the treatment landscape for rheumatologists.

Below is a preview of the conversation:

Rheumatology Network: What are some of the controversies and osteoporosis that you discuss in your presentation?

E Michael Lewiecki, MD: Well, it's interesting that almost everything we do in the field of osteo process has some controversial aspects to it. One thing that is somewhat confusing is conflicting clinical practice guidelines. There are numerous guidelines that are published and available on websites that inform healthcare professionals about how to manage patients with osteoporosis. And sometimes the recommendations are a little bit different and they often address different specialties. You know, 1 set of guidelines might be directed to endocrinologists, another to rheumatologists, another to primary care physicians. Some only are focused on a particular population of patients, such as postmenopausal women, some involve women and men, some are directed to subclasses of these patients such as glucocorticoid-induced osteoporosis. So, it can be a bit daunting to wade your way through all these guidelines and, you know, come up with the right kind of decision making that you need for your particular patient who is in front of you. I can mention a few other controversies. Another one has to do with how long to treat. There's a myth out there that all osteoporosis medicines should be stopped after 3 years or 5 years. And often that is done without regard to the level of fracture risk that the patient has or what medication they're on. And this idea of drug holidays was conceived years ago, and it just needs to be emphasized that the idea of a drug holiday only applies to patients on bisphosphonates. There's no drug holiday with any other medication. It's not a rule, it's just a consideration, that if a patient has been treated for 3 to 5 years with a bisphosphonate and fracture risk is no longer high, that they might be considered to get off of the medication for a year or a couple of years, be monitored, and sooner or later get back on to some sort of treatment when fracture risk is once again high. And for that reason, it's not called drug retirement it's just a drug holiday. Another controversy is what to do after stopping denosumab. This is a very potent, anti-resorptive agent that's given as a subcutaneous injection every 6 months. And soon after that 6-month period the effects of the medicine rapidly dissipate. Bone density can go down quickly. Bone turnover markers rise and go even higher than baseline and fracture risk goes back to baseline very quickly. And in some patients, there may be a risk of multiple vertebral fractures. So, patients stopping treatment with denosumab need to be followed up with another drug to try to mitigate that downward trend in bone density that might otherwise happen. And often, the drug that's given is a bisphosphonate. There is some uncertainty about which bisphosphonate might be best and how to administer it. Often the bisphosphonate used is zoledronic acid and there's consideration given to whether it should be given 6 months after the last dose of denosumab a little bit longer after the last dose of denosumab and whether the effects of that might be monitored with bone turnover markers in addition to bone density. And perhaps, in some patients, a second dose of zoledronic acid given sooner than 1 year after that first dose might be needed. So, a lot of active investigation into that sort of thing.

RN: Have you noticed any trends in treatment over the past year?

EML: Well, there's been challenges with code because some patients on injectable treatments that are given by a healthcare professional have been reluctant to go to a physician's office. And for that reason, some treatments have been delayed. So we've gone to a great deal of trouble to be innovative in giving treatments. For example, some patients who are on denosumab need an injection every 6 months and have not been willing to come inside the office. We've actually done drive-thru injections of denosumab in the parking lot. We've had patients drive into the parking lot, call us on their cell phone and a nurse has gone out to the car, patients rolled down the window, stuck their arm out, and we given them their injection. So, things like that are kind of new and different because of COVID. We're all having to adapt to the new world situation that we live in.

RN: Do you have any predictions for osteoporosis or osteoarthritis moving into 2022?

EML: Well, as I've learned in recent years, it's dangerous to make predictions about anything. But what I hope to see is a move towards, at least on a minimal level, is some harmonization of clinical practice guidelines. Since there are no new osteoporosis drugs in the clinical practice pipeline right now, I think we're all going to learn how to use better the medicines that we currently have. And I think there'll be more emphasis on this important concept of sequence of therapy making a difference in how patients respond. I think more recognition that patients at very high fracture risk may benefit from initial therapy with anabolic agents. And I think we're going to be seeing more biosimilar drugs for some of the ones that are now fairly expensive, at least in the US. And I hope to a certain degree that will help prices to come down in some of the drugs that are pretty expensive right now.