The International Osteoporosis Foundation (IOF) has published practical guidelines to assist clinicians in assessing treatment efficacy in patients who experience a fracture while on medication for osteoporosis.
Osteoporosis drug therapy typically reduces the risk of fracture in the range of 30-70% for vertebral fractures, 40-50% for hip fractures and 15-20% for non-vertebral fractures. Nevertheless, even an effective therapy does not completely eliminate the risk of fracture, and some patients will experience a fracture while complying with their prescribed treatment.
This situation is not just worrying for the patient, it also poses a challenge for the physician who must decide whether to continue or discontinue with the treatment regimen. Does the fracture signify that the patient has failed to respond to the particular treatment? Should the type of treatment be changed? Or is the patient one of a significant minority who fails to respond to available treatments, for a number of many possible reasons?
The IOF Inadequate Responders Working Group, comprised of international experts on IOF's Committee of Scientific Advisors, outlines many of the issues associated with clinical decisions in the treatment of osteoporosis. Professor Adolfo Diez-Perez, chair of the Working Group, explains, "Treatment issues are extremely complex. In addition there is a scarcity of data about the effectiveness of alternative treatments when one has been deemed to have failed. Notwithstanding these complexities and limitations, the Working Group has used the best available evidence to create a check list of pragmatic criteria which can help doctors define treatment failure and take appropriate action."
The position paper, published in the journal 'Osteoporosis International', outlines how the response to treatment in patients who have been complying with their treatment for at least six months can be assessed on the basis of the number of fractures, changes in bone mineral density and bone turnover markers.
Professor Cyrus Cooper, chair of the IOF Committee of Scientific Advisers, stated: "Recent advances in the management of osteoporosis have led to large numbers of patients being treated with a variety of drugs. An increasingly frequent clinical conundrum is the management of a patient who sustains a fracture while on treatment. Although patient and physician may view this as a sign of treatment failure, this is not always the case. The objective of the current practical guidance was to provide a clinical pathway whereby physicians can ascertain whether a patient has failed to respond adequately to an anti-osteoporosis treatment. As a result, doctors will be able to define treatment failure more effectively, and take appropriate action. The algorithm produced pays testimony to the expert input from a host of international scientific advisers, coming together to address this important clinical topic in a timely and efficient manner."
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Treatment failure in osteoporosis A. Diez-Perez, J. D. Adachi, D. Agnusdei, J. P. Bilezikian, J. E. Compston, S. R. Cummings, R. Eastell, E. F. Eriksen, J. Gonzalez-Macias and U. A. Liberman, et al. Osteoporosis International 2012, DOI: 10.1007/s00198-012-2093-8