Difficult Choices in Long-term Osteoporosis Management
SOURCE: Leder BZ, et al. Denosumab and teriparatide transitions in postmenopausal osteoporosis (the DATA-Switch study): Extension of a randomised controlled trial. Lancet 2015;386:1147-1155.
The propriety of long-term bisphosphonate utilization (that is, > 5 years) has recently come into question subsequent to a clinical trial that compared bisphosphonate discontinuation at 5 years vs continuation for 10 years. Despite a decline in bone mineral density (BMD) in the cessation group, the actual hip fracture rate was no greater than in the group who continued bisphosphonate for 10 years. Since there are adverse effects and expense associated with treatment, many questions remain about how long to treat and which agent(s) to utilize.
In the DATA (Denosumab and Teriparatide Administration) trial, postmenopausal women (n = 94) with osteoporosis were randomized to treatment with teriparatide (TER), denosumab (DEN), or both for 2 years. DATA-Switch is an extension of DATA, during which patients on monotherapy were switched (e.g., if on DEN for 2 years, switched to TER, and vice versa), and patients on dual therapy (DEN + TER) were switched to DEN monotherapy. The SWITCH phase of the trial lasted an additional 2 years. TER patients switched to DEN, and DEN + TER patients switched to DEN monotherapy continued to accrue more mass at the lumbar spine, distal radius, femoral neck, and total hip. Women who were switched from DEN to TER lost BMD at the distal radius, and showed losses of BMD in the femoral neck and total hip for the first 12 months, after which some gain in BMD occurred.
Ultimately, the greatest improvements in BMD were seen in women who were assigned initially to DEN + TER and then switched to DEN monotherapy. Hopefully, we will see similar trials in the future to guide us in switching between bisphosphonates and alternative agents such as denosumab.
The greatest improvements in bone mineral density were seen in women who were assigned initially to a combination of denosumab and teriparatide and then switched to denosumab monotherapy.
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