Is anabolic therapy indicated in patients with a recent fracture?

Anabolic Therapy is Indicated for Patients with Recent Fractures and Very High Fracture Risk

Anabolic therapy is indicated for patients with a recent fracture, particularly those with very high risk of subsequent fractures. 1 This recommendation is supported by multiple guidelines that recognize the superior efficacy of anabolic agents in rapidly reducing fracture risk compared to antiresorptive therapies.

Patient Risk Stratification

Patients with recent fractures should be stratified into risk categories:

• Very High Risk (anabolic therapy indicated):

  • Recent fracture (within past 24 months) 1
  • Multiple clinical risk factors, particularly older age and glucocorticoid use 1
  • Severe osteoporosis with T-score ≤ -2.5 and fragility fractures 1

• High Risk (antiresorptive therapy appropriate):

  • Single risk factor without recent fracture 1
  • Less severe bone density loss

Evidence Supporting Anabolic Therapy After Fracture

The European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) and International Osteoporosis Foundation (IOF) recommend that patients at very high risk of fracture should be directed to more efficacious anabolic therapy first 1. This recommendation is based on evidence that:

1. Fracture risk is acutely elevated immediately after an index fracture 1
2. 31-45% of recurrent fractures occur within 1 year of the first fracture 1
3. Anabolic agents demonstrate greater and more rapid therapeutic effects than oral antiresorptives 1

Available Anabolic Agents

Two primary anabolic options are available:

1. Teriparatide:

   • FDA-approved for men and women with osteoporosis at high risk for fracture 2
   • Increases lumbar spine BMD in 94% of treated patients 2
   • Limited to 24 months of treatment due to theoretical osteosarcoma risk 2

2. Romosozumab:

   • Indicated for postmenopausal women with osteoporosis at high risk for fracture 3
   • Limited to 12 monthly doses, after which therapy should transition to an antiresorptive agent 3

Treatment Sequence Considerations

For optimal long-term outcomes:

1. Start with anabolic therapy in very high-risk patients with recent fractures 1, 4
2. Follow with antiresorptive therapy (bisphosphonate or denosumab) to maintain gains 3, 4
3. This sequence maximizes bone density accrual compared to starting with antiresorptives 4

Practical Considerations

• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation during anabolic therapy 1, 2
• Monitor for side effects:
  • Teriparatide: hypercalcemia, orthostatic hypotension 2
  • Romosozumab: cardiovascular risk (use with caution in patients with cardiovascular disease) 3

Common Pitfalls to Avoid

1. Delaying anabolic therapy: The highest fracture risk is in the immediate post-fracture period; early intervention with anabolic therapy can significantly reduce this risk 1

2. Inappropriate sequencing: Starting with antiresorptives before anabolic therapy results in suboptimal bone density gains 4

3. Inadequate treatment duration: Ensure full course of anabolic therapy (12-24 months depending on agent) followed by antiresorptive therapy 2, 3

4. Neglecting calcium/vitamin D: These supplements are essential components of all osteoporosis treatment regimens 1, 2

In conclusion, anabolic therapy should be strongly considered as first-line treatment for patients with recent fractures, particularly those at very high risk for subsequent fractures, to rapidly reduce fracture risk and optimize long-term outcomes.