Managing Osteoporosis in the Era of COVID-19

COVID-19 is delaying and disrupting the treatment of many patients with osteoporosis, so the American Society for Bone and Mineral Research (ASBMR) set up a steering committee of bone specialists to consider how best to manage these patients.

In April, this committee held a webinar to look at the issues and the evidence, and this informed guidance issued jointly in May by the American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and the National Osteoporosis Foundation (NOF).  A paper on the evidence behind the recommendations has recently been published in the ASBMR’s official journal, the Journal of Bone and Mineral Research.

“We have no evidence that any of the medications that we use to treat osteoporosis affect COVID-19 in any way, so we don’t think that any of these medications is going to be harmful to someone already infected or will increase their risk of infection,” says steering committee member Matthew Drake, M.D., of the Division of Endocrinology and Kogod Center on Aging, Mayo Clinic College of Medicine, Rochester, Minnesota.

“It is mostly a question of how can we avoid any negative repercussions that can come with discontinuation of some of these medications and how can we continue to provide them in the safest possible way.”

The main challenge in managing osteoporosis at this time is the need to maintain social distance, he says, so where possible consultations should be done remotely, via telephone or video link; most bone mineral density examinations and lab work ups should be postponed or worked around; and elective procedures should largely be avoided.

Standard pre-treatment labs for IV bisphosphonates and/or denosumab can be avoided if results within the last year were normal and the rheumatologist considers the patient’s health to be stable, the guidelines say. However, laboratory evaluation is recommended for patients with fluctuating renal function and those at higher risk for developing hypocalcemia, including those with malabsorptive disorders, hypoparathyroidism, advanced renal dysfunction (chronic kidney disease stage 4 or 5), or taking loop diuretics.

The guidelines emphasise that patients should continue osteoporosis medications, including oral and intravenous (IV) bisphosphonates, denosumab, estrogen, raloxifene, teriparatide, abaloparatide, and romosozumab, when possible to do so safely, and that initiation of new oral bisphosphonate therapy can be done remotely and should not be delayed in patients at high risk for fracture.

Less frequent administration of IV bisphosphonates is unlikely to have much of an impact in the short term as these injections usually last a long time and are generally given either annually or every few months, Dr. Drake says.

Daily or monthly injections of medications to build up bone should be continued as much as possible, although a break of a few months may be necessary if it is not felt safe to administer and should not have too much of an impact, he adds. The biggest issue is with the administration of drugs that try to prevent bone being lost, such as romosozumab and denosumab, but particularly denosumab.

There is evidence that a delay in denosumab treatment causes rebound high bone turnover and rapid bone loss within one year, thereby increasing the risk of multiple vertebral fractures. Vertebral fractures have been reported as early as seven months after the last denosumab injection. Discontinuing romosozumab causes rapid bone loss within one year if not followed by another osteoporosis treatment, with indices of bone resorption increasing within three months, although this has not been linked to an increased risk of fractures.

The guidelines make several recommendations as to how medications such as these can be administered while maintaining social distancing. These include: off-site clinics located geographically away from covid-19 “hot-spots”, home delivery with either self-administration or administration by a visiting health professional, and drive-through clinics.

The drive-through and off-site clinics would generally not be options for people without their own vehicle, Drake says, as you would not want patients to travel using public transport. Some drive-through clinics are in operation for established patients, he says. “Patients drive up to the clinic, they hold out their arm and are given the injection. They drive to another part of the parking lot for 10 minutes to make sure they’re okay and if everything is fine, they are good to go.”

Home administration is an option for most people as it is “a fairly straightforward procedure” that in most cases does not require a health professional to visit for administration, if there is concern that this would put them at greater risk of infection, he adds.  Patients could self-inject with some coaching over the computer, or perhaps ask a family member or neighbour who was a healthcare worker to administer the drug.

While some drugs, such as denosumab, are licensed only for administration by healthcare professionals, the US FDA is now allowing more flexible arrangements during the pandemic, if approved by a healthcare provider and following appropriate instruction. It allowed Amgen, the licensee of Prolia (denosumab), to issue a letter to doctors on 21 May stating that  “while administration of Prolia by a healthcare provider remains the preferred mode of administration where possible, there may be cases where the healthcare provider determines that self-administration of Prolia by a patient or lay caregiver may be temporarily warranted in the context of local COVID 19-related guidelines and restrictions, and individual patient factors”.

As the months pass, it might be necessary to think about transitioning some patients to other treatments such as oral bisphosphonates, Drake points out. Drugs that build bone are normally administered for one year or 18 to 24 months before a patient would normally transition to a drug that prevents bone loss. “It then becomes a question of how patients get those medications once the first options are finishing,” he says.