An expert discusses the state of screening, diagnosing, and treating osteoarthritis and osteoporosis.
Osteoarthritis and osteoporosis are common conditions in which millions of patients are affected worldwide. Despite the common nature of the diseases, patients are not often regularly scanned to see if they have 1 of them. Instead, they suffer pain and have an increased risk of fragility fractures and worse quality of life.
Nancy Lane, MD, of UC Davis Health is an expert in osteoarthritis and osteoporosis who spoke at the Congress of Clinical Rheumatology East 2020 meeting about the state of both diseases today. HCPLive® had the opportunity to speak with Lane about the 2 spaces, popular agents for the treatments of the diseases, and why patients are being scanned regularly for the conditions.
HCPLive: What’s going on in the world of osteoarthritis right now?
Lane: It's an exciting time in the space of osteoarthritis. There's tremendous work being done in the basic science of the disease and there are some very exciting translational phase 2-type studies that are right now recruiting patients that are looking at agents that can stimulate the cartilage to grow and thicken, that can reduce the degradation and increase cartilage matrix formation. There are studies just reported where inhibitor seville 1 reduced joint replacements over 3.5 years by over 50% and a group of agents that by themselves don't reverse or slow the course of the disease, but are an actual inhibitor of pain in the joint by a novel pathway of inhibiting nerve growth factor, that compound tanezumab may be available to our patients in the early part of next year.
So, those are some examples of the excitement in terms of new therapeutics. In addition, although I will not be spending a lot of time talking about this, there finally has been a way to get stem cells to turn into cartilage and grow cartilage. It's a little bit complicated, but it requires some skeletal stem cells and then giving it a growth factor and a factor to inhibit new blood vessel formation, anti-VEGF, and cartilage has now been generated in a mouse where there's been a defect. And if we can translate any of that to the clinic, we're really going to be able to help our patients.
HCPLive: What agents are you most excited about?
Lane: Well to inhibit pain for a prolonged period of time, I'm excited about the inhibition of nerve growth factor of the tanezumab work. For the IL-1 inhibitor, the data are for canakinumab. The stem cell work is in its infancy and is being done out of Stanford.
HCPLive: You’re also an expert in osteoporosis. How do you individualize treatment for that condition?
Lane: Well, that's a great question. We look at it in terms of patients who are at high risk for fracture and we try to prevent fractures by giving them long-acting bisphosphonates or other inhibitors. Then we have patients who present to us and they've already had fragility fractures. And for those patients I will emphasize starting them on an anabolic agent, either teriparatide, abaloparatide, or romosozumab followed then by a strong and resorptive agent to maintain that bone that they have gained and maintain their improved bone strength.
HCPLive: It's interesting you bring up bisphosphonates. I was actually just looking at an abstract that was presented earlier today at the North American Young Rheumatologists Investigator Forum and the investigators noted how osteoporosis is a condition a lot of patients are not necessarily screened for. Why is that?
Lane: Well, that's a great question. There's been a sea change over the last 10 years. Ten years ago, many physicians had bone density machines in their office, and they would do the scans right there and interpret them. However, there was a change in reimbursement and it resulted in many of the bone density machines no longer being available, except in hospitals or in large clinics, which for some reason, has reduced physicians and healthcare providers’ interest in getting bone densities, and the result being less people are treated for their osteoporosis and then osteoporosis comes to the attention of the physician later when there's a fragility fracture. That alone is a diagnosis of osteoporosis. But actually, screening and treating people at high risk, we're lucky if we can do it, lucky if it's done at age 65.
Now, the guidelines are very clear. All women should have a bone density scan at age 65 and all men at the age of 70. Women below the age of 65 should if they've had a fragility fracture or have significant risk factors. So, all women for the most part should be screened by age 65 and all men at age 70, but that's rarely happening today. As a result, we are seeing more fragility fractures in our population.
HCPLive: How detrimental can that be?
Lane: Well, the first fracture by itself, say it’s a vertebral fracture, may not be detrimental. But 1 fracture significantly increase your risk of another fracture and another fracture, at which point, with the vertebral fractures, you're losing height, you're bent over, and your quality of life goes down. So, we really need to try to recognize that first fracture and get it treated. If we can't do it before the fracture, then we definitely need to do it when they first have a fragility fracture.
HCPLive: How are you able to do that without the machinery?
Lane: Well, it's difficult, but the patients who have a clinical or painful vertebral fracture, or an osteoporotic fracture fragility fracture by say, falling from a high standing height. Hopefully they will get referred to fracture liaison services or to doctors that will work them up. Otherwise, if we don't catch them at the first couple of fractures, that's a bad position to be in. So, we all have to be on the lookout for these patients. Rheumatologists are very good at identifying these patients. We see older patients with other musculoskeletal ailments and rheumatologists tend to be pretty vigilant about getting bone densities, assessing our patients, treating them, and following them.
HCPLive: Is there anything else you would like to add about osteoarthritis or osteoporosis that is happening right now?
Lane: The most important thing is that physicians recognize the need for every woman over 65 and every male over 70 to have a bone density scan. If they're treated, remember after 3 years to check their bone densities to see if they've improved, or if they haven't fractured and they've been on intravenous bisphosphonates, then they should have a drug holiday. If they've been on oral for 5 years and they aren’t having fractures and their bone density is good, they should be on a drug holiday and remember to follow them. Remember to see them in about 2-3 years and reassess them because many patients after these holidays slip back into needing therapy.
Another very important thing to remember is osteoporosis is like any chronic disease of aging. Once you have it, you always have it and your risk of fracture may change but you need to assess for it the rest of a patient's life.