Interview with Professor Xia Weibo: The only way to treat osteoporosis with drugs - long-term treatment

With the aging of the social population, the prevalence of osteoporosis in China has risen sharply
.

Effective prevention and control of osteoporosis and reducing the incidence of osteoporotic fractures are of great significance for reducing the harm of the disease to national health and social economy
.

At present, osteoporosis treatment drugs mainly include bone resorption inhibitors, bone formation promoters, etc.
Long-term drug treatment can continuously increase bone density and reduce fracture risk, which is an inevitable trend of osteoporosis drug treatment, but based on fracture risk The scientific sequential treatment plan still needs to be further explored
.

Recently, we specially invited Professor Xia Weibo of the Chinese Academy of Medical Sciences and Peking Union Medical College Hospital to accept an exclusive interview.
Starting from the current situation of osteoporosis diagnosis and treatment in China, we shared the necessity of long-term continuous treatment, different sequential programs and future prospects for bone-promoting drugs.

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Expert introduction Professor Xia Weibo, MD, chief physician, professor, doctoral tutor, director of the Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, director of the National Health and Health Commission's Key Laboratory of Endocrinology, director of the Chinese Medical Association, Osteoporosis and Bone Mineral Disease Branch The fifth chairman, member of the Standing Committee of the Endocrinology Branch of the Chinese Medical Association, member of the Standing Committee of the Endocrinology Professional Committee of the Chinese Medical Doctor Association, deputy director of the Endocrine Branch of the Beijing Medical Association, member of the Standing Committee of the Branch of Osteoporosis and Bone Mineral Diseases, and Scientific Advisory Committee of the International Osteoporosis Foundation Director, Director of Asia Pacific Osteoporosis Alliance
.

Professor Xia Weibo was interviewed by Yimaitong.
Yimaitong: You just published "The Only Way to Treat Osteoporosis: Long-term Treatment" 1.
You mentioned that in the treatment of osteoporosis, long-term treatment is very important.
You Can you talk briefly? Professor Xia Weibo: First of all, the harm of osteoporosis is huge, and anti-osteoporosis treatment is urgent
.

The results of the seventh census show that the total population of mainland China will reach 1.
41 billion in 2020, of which the total number of elderly people aged 60 and above will be 264 million, accounting for 18.
7% of the total population.
fast lane"
.

At the same time, according to large-scale epidemiological studies, the prevalence of osteoporosis in people over 50 years old in China is 19.
2%, and the prevalence of osteoporosis in female patients is as high as 29.
1%.
The prevalence of osteopenia was as high as 46.
4%
.

At the same time, the awareness rate, diagnosis rate and treatment rate are low
.

At present, the diagnosis and treatment rate of osteoporosis in China is worrying.
The awareness rate of patients over 50 years old is only 7.
0%, and the proportion of patients who have received bone density testing is only 3.
7%
.

A cross-sectional study in China shows that only 1.
4% of women with osteoporosis or fractures over the age of 40 are receiving anti-osteoporosis treatment; even if fragility fractures occur, the diagnosis and treatment rate is significantly insufficient
.

A retrospective study suggests that only 44.
8% and 73.
3% of patients who were discharged from hospital with hip and vertebral fractures were diagnosed with osteoporosis, and only 14% were given effective anti-osteoporosis treatment after surgery
.

At the same time, the harm of osteoporosis is serious and the social burden is huge
.

The most serious consequence of osteoporosis is fracture under mild external force, which is called fragility fracture, which leads to multiple complications such as bone pain, physical disability, pneumonia, bedsore, deep vein thrombosis, etc.
, and the fatality and disability rate is extremely high
.

Among them, hip fractures and vertebral fractures can reduce the life expectancy of patients
.

The mortality rate of long-term bedridden patients can reach 20% within one year, and the permanent disability rate can reach 50%, which brings a heavy economic burden to the family and society
.

The substantial economic burden of osteoporotic fractures is projected to exceed $25 billion by 2050
.

Secondly, long-term treatment of osteoporosis is inevitable
.

Human aging is an irreversible process.
Osteoporosis is a progressive disease that requires lifelong anti-osteoporosis treatment
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The main pathogenesis of osteoporosis is the imbalance of bone turnover, that is, bone resorption is accelerated, and bone formation is relatively insufficient, which gradually leads to bone loss and osteoporosis
.

In view of this pathogenesis, the current effective therapeutic drugs for osteoporosis are mainly divided into bone resorption inhibitors and bone formation promoters
.

However, there are certain duration limitations in the treatment of osteoporosis drugs, such as the bone formation-promoting drug teriparatide, which is approved for 2 years for the treatment of osteoporosis, while the drugs that inhibit bone resorption, such as bisphosphonates (BPs) , Oral BPs treatment for 5 years and intravenous BPs treatment for 3 years may increase the bone mineral density (BMD) to a plateau, and it is necessary to consider stopping the treatment and entering the drug holiday as appropriate
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It can be seen that single drug treatment is difficult to achieve the purpose of long-term disease prevention and control, and long-term continuous treatment is an inevitable strategy for osteoporosis drug treatment
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 Professor Xia Weibo was interviewed by Yimaitong: How to carry out sequential treatment? Professor Xia Weibo: In recent years, the American Academy of Clinical Endocrinology (AACE) and other guidelines have recommended individualized osteoporosis drug treatment according to fracture risk stratification.
, denosumab, teriparatide, abalatide or monoclonal antibodies to sclerostin,
etc.

Here are three types of anti-osteoporosis drugs that are strong and effective for patients with high and very high risk of fractures—BPs, teriparatide, and denosumab.
Riparatide or Denosumab treatment: BPs are one of the main osteoporosis treatment drugs
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The study will have received alendronate, risedronate, etidronate and non-bisphosphonate treatment group, followed by teriparatide treatment for 2 years, the results showed that a variety of bisphosphonate sequence.
Treatment with teriparatide significantly increased lumbar spine and hip BMD
.

BPs sequential denosumab decreased bone resorption index more significantly, BMD increased significantly, the effect was better than BPs drug continuous treatment, suggesting that BPs can also be treated sequentially with bone resorption inhibitor denosumab
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Second, teriparatide followed by BPs or denosumab: Teriparatide is currently approved for a 2-year course of treatment
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Studies have shown that after teriparatide is discontinued, the biochemical indicators of bone turnover and BMD will decrease rapidly, so other anti-osteoporosis drugs must be sequenced to consolidate its therapeutic effect
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Teriparatide can be treated sequentially with BPs or denosumab, that is, using bone formation promoters first, followed by bone resorption inhibitors, which can further improve bone density and reduce fracture risk
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Third, denosumab followed by BPs or teriparatide treatment: after denosumab is discontinued, BMD will decrease rapidly, and the risk of fractures, especially multiple vertebral fractures, will increase significantly, suggesting that once denosumab is discontinued Monoclonal antibody must be treated sequentially with other anti-osteoporosis drugs
.

A recent study of osteoporosis patients receiving denosumab treatment followed by zoledronic acid treatment after discontinuation of the drug showed that the BMD of the lumbar spine and hip was still decreasing in the first year of sequential zoledronic acid treatment.
, the bone resorption index increased, and BMD remained stable until the second year of zoledronic acid treatment
.

In addition, the sequential treatment of denosumab followed by teriparatide also further improved bone mineral density
.

It can be seen that osteoporosis is a chronic disease with high prevalence, serious harm, and long-term treatment.
It is of great clinical significance to carry out long-term treatment with a variety of anti-osteoporosis drugs
.

Although bisphosphonates, teriparatide, and denosumab can significantly increase BMD in patients with osteoporosis, they are all short-acting drugs, and BMD will decrease rapidly after drug withdrawal.
Only then can BMD continue to increase, and ultimately the patient's bone density can be kept stable, and the risk of fracture can be significantly reduced
.

Prof.
Xia Weibo was interviewed by Yimaitong: The data shows that compared with developed countries, the clinical use of bone-promoting agents in my country is much lower than that of bone resorption inhibitors.
What do you think is the biggest problem at present? What are your expectations for the future? Professor Xia Weibo: First of all, drugs that promote bone formation are indispensable in the treatment of osteoporosis.
Compared with European and American countries, the drugs that promote bone formation in China are late in the market.
It is one of the first choices for patients with very high fracture risk recommended by multiple guidelines and consensuses
.

Secondly, the imported teriparatide is expensive for osteogenesis drugs on the market in China, and the domestic powder injection is inconvenient to inject, and neither of them is included in the medical insurance catalogue, which makes it difficult for patients to accept it and cannot meet the huge patient population
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In the future, it is hoped that more convenient and cost-effective osteogenesis drugs will be launched, such as teriparatide weekly preparations, which can improve patient compliance, increase confidence in drug use, and bring greater clinical benefits
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References for the survey questionnaire: 1.
Li Mei, Zhang Zhenlin, Xia Weibo.
The only way for osteoporosis drug treatment: long-term treatment [J].
Chinese Journal of Osteoporosis and Bone Mineral Diseases, 2021, 14(05): 441 -446.