E Michael Lewiecki, MD: Sequential Therapy in Osteoporosis

Rheumatology Network sat down with E Michael Lewiecki, MD, Director at the New Mexico Clinical Research and Osteoporosis Center, to discuss his CCR West presentation “Sequential Therapy in Osteoporosis: When Does the Order Matter?” We discuss sequential therapy in terms of osteoporosis treatment and why it is important for a rheumatologist to understand this method of treatment.

E Michael Lewiecki, MD

Rheumatology Network: What does sequential therapy mean in terms of treating patients with osteoporosis?

E Michael Lewiecki, MD: For a patient who's at high risk for fracture, any treatment is better than none. But some treatments are better than others. Current guidelines suggest that we do fracture risk stratification to help us decide what the initial therapy should be. And recent studies have shown that patients at very high risk for fracture have better reduction of fracture risk if they begin treatment with an anabolic agent than if they begin with an antiresorptive agent. So, the order of treatment is actually quite important, and this includes patients with glucocorticoid-induced osteoporosis that rheumatologists see a lot of. So, beginning with an anabolic agent, followed by an antiresorptive agent, gives you the best reduction in fracture risk and the most rapid and highest increase in bone density.

If you do the reverse order, if the sequence of therapy is antiresorptive therapy followed by an anabolic agent, then the effects of the anabolic agent will be delayed or attenuated by the effects of the antiresorptive agent. So, the general theme is if you recognize that somebody is at very high risk of fracture, then you should consider beginning with an anabolic age or at the very least have that discussion with the patient. This is quite the opposite of something that is called step therapy, which is kind of the traditional way that health plans like to think of medicine. Step therapy means starting with the least expensive medication, which is often a generic bisphosphonate, and only going to something else if that does not work or if it is contraindicated. But there are other drugs that can provide a bigger increase in bone density and a greater reduction in fracture risk that may be more appropriate in some individual patients.

RN: Why is it important for a rheumatologist to understand this sequential method of treatment?

ML: Well, it's important for rheumatologist because rheumatologists see a lot of patients who are at a very high risk for fracture. There are examples in some of the guidelines as to what constitutes very high risk as opposed to high risk, or the typical high-risk patient. Perhaps a bisphosphonate or denosumab might be perfectly appropriate. But for a very high-risk patient who has an extremely low bone density, or a patient with a recent major fracture or multiple osteoporotic fractures, there may be examples of very high-risk patients where anabolic therapy should be considered as initial therapy.