Who manages anti-absorptive (anti-resorptive) therapies for osteopenia?

Management of Anti-Absorptive Therapies for Osteopenia

Anti-absorptive therapies for osteopenia should be managed through a coordinated approach between oncologists and primary care physicians, with transition of care occurring as appropriate based on the patient's cancer treatment status and risk factors. 1

Responsible Healthcare Providers

The management of anti-absorptive therapies for osteopenia involves several healthcare providers depending on the clinical context:

• During active cancer treatment: The primary oncology treatment team typically manages bone health interventions 1
• During transition period: Coordination between oncology and primary care is essential 1
• After completion of cancer treatment: Primary care physicians often take over management of osteoporosis/osteopenia 1
• Specialists may be involved in complex cases:
  • Endocrinologists
  • Rheumatologists
  • Metabolic bone disease specialists

Decision-Making Framework for Anti-Absorptive Therapy

Risk Assessment

1. Evaluate fracture risk factors:

   • Age >65 years
   • BMI <24
   • Family history of hip fracture
   • Personal history of fragility fracture
   • Smoking status
   • Oral glucocorticoid use >6 months 1

2. Bone density measurement:

   • Dual-energy X-ray absorptiometry (DEXA) scan of spine and hip
   • T-score interpretation:
     • Normal: >-1.0
     • Osteopenia: -1.0 to -2.5
     • Osteoporosis: ≤-2.5 1

3. Calculate fracture risk:

   • FRAX (Fracture Risk Assessment Tool) to determine 10-year fracture risk 1

Treatment Algorithm

For Cancer Patients on Endocrine Therapy:

• T-score >-2.0 with no additional risk factors:

  • Monitor BMD every 1-2 years
  • Calcium and vitamin D supplementation 1

• T-score >-2.0 with two or more risk factors:

  • Consider bisphosphonate therapy
  • Monitor BMD every 2 years 1

• T-score ≤-2.0:

  • Initiate bisphosphonate therapy or denosumab
  • Calcium and vitamin D supplementation
  • Check compliance with oral therapy 1

For Patients with Glucocorticoid-Induced Osteopenia:

• For adults with high or very high fracture risk:
  • Strongly recommended to use osteoporosis therapy over calcium and vitamin D alone
  • Oral bisphosphonates are strongly recommended as first-line therapy 1
  • For very high risk, consider PTH/PTHrP over anti-resorptives 1

Medication Selection and Monitoring

First-line Options:

• Bisphosphonates:

  • Oral: Alendronate (weekly), risedronate (weekly), ibandronate (monthly)
  • IV: Zoledronic acid (every 6-12 months) 1

• Denosumab:

  • 60mg subcutaneously every 6 months
  • Particularly effective for patients on aromatase inhibitors or ADT 1, 2

Monitoring:

• Repeat DEXA scans every 1-2 years 1
• If annual decrease in BMD ≥10% (or ≥4-5% in patients who were osteopenic at baseline), evaluate for secondary causes of bone loss 1

Special Considerations

For Breast Cancer Survivors:

• Postmenopausal women on aromatase inhibitors should have DEXA scans every 2 years 1
• If major risk factors change, consider repeat DEXA at 1 year 1
• Adjuvant bisphosphonate therapy may be considered for 3-5 years for postmenopausal women and those receiving ovarian function suppression 1

For Prostate Cancer Patients on ADT:

• Denosumab has specific license for treatment-induced bone loss associated with ADT 1
• Bisphosphonates or denosumab should be considered for men with NMPC receiving GnRH agonists 1

When Discontinuing Therapy:

• If stopping denosumab, transition to bisphosphonate therapy to prevent rebound bone loss 1
• If stopping glucocorticoids with no new fragility fracture and BMD T-score >-2.5, consider stopping anti-resorptive therapy 1

Care Coordination

A treatment summary and individualized care plan should clearly identify the healthcare provider responsible for bone health management 1. This ensures continuity of care and prevents gaps in monitoring and treatment.

Common Pitfalls to Avoid

• Failure to assess baseline risk: Always perform comprehensive fracture risk assessment before initiating therapy
• Inadequate monitoring: Regular DEXA scans are essential to evaluate treatment response
• Overlooking dental health: Dental screening exam should be performed before initiating bisphosphonates or denosumab to reduce risk of osteonecrosis of the jaw 1
• Abrupt discontinuation of denosumab: Can lead to rebound vertebral fractures; transition to bisphosphonate therapy is recommended 1
• Lack of care coordination: Clear communication between oncology and primary care is essential for continuity of care 1