New options in osteoporosis therapy: Combination and sequential treatment

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March 2003 · Vol. 15, No. 3

New options in osteoporosis therapy: Combination and sequential treatment

Perhaps the biggest medical question to emerge from the WHI study is how to best treat postmenopausal osteoporotic women. Could the answer lie in combining 2 current monotherapies?

ROBERT L. BARBIERI, MD

Dr. Barbieri is the Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and chief of the department of obstetrics and gynecology at Brigham and Women’s Hospital in Boston. He also serves as OBG Management’s Editor-in-Chief.

KEY POINTS

Combination or sequential therapy may benefit the approximately 15% of osteoporosis patients who continue to lose bone on monotherapy.
Greater bone-density increases result from bisphosphonate plus either estrogen or raloxifene than from single-agent therapy.
The introduction of parathyroid hormone (PTH) (1-34), a therapy that stimulates bone formation, will likely result in development of combination or sequential regimens of PTH plus an antiresorptive agent.
Estrogen may be indicated early in the transition to menopause, but many authorities recommend switching to a bisphosphonate in late postmenopause.
For menopausal women with a recent osteoporotic fracture, 1 month of calcitonin treatment may help increase bone density and reduce fracture pain. After the pain has resolved, a bisphosphonate, raloxifene, or PTH can be started.

While the headline-grabbing Women’s Health Initiative (WHI) study has been alerting clinicians and patients alike to the risks and benefits associated with hormone replacement therapy (HRT), a series of lower-profile investigations offers new hope to osteoporotic women.

Numerous clinical trials have demonstrated that approximately 15% of women with osteoporosis who are treated with a single drug continue to lose bone mass^1,2; particularly resistant are cigarette smokers and women with a body weight below 130 lb.³

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