Osteoporose-Update 2021

Was ist neu?

Romosozumab Romosozumab ist ein humanisierter Antikörper gegen das Osteozyten-spezifische Protein Sklerostin. Die Neutralisierung von Sklerostin mit Romosozumab fördert die Knochenneubildung. Die schnelle Zunahme an Knochenmasse reduziert deutlich das Frakturrisiko und geht bereits nach einem Jahr in ein Plateau über. Als Erhaltungstherapie ist eine anschließende antiresorptive Therapie erforderlich. Romosozumab ist zugelassen als neues anaboles Wirkprinzip für die Behandlung der schweren Osteoporose. Es besteht ein Warnhinweis für kardiovaskuläre Erkrankungen wie Myokardinfarkt oder Schlaganfall in den letzten 12 Monaten.

Primär anabole Therapie Nach Aufhebung des G-BA-Therapiehinweises zu Teriparatid mit dem 06.04.2019 ist eine primär anabole Therapie der Osteoporose ohne vorherige antiresorptive Behandlung möglich. Das Vorgehen sollte individualisiert an die Krankheitsaktivität und das Frakturrisiko angepasst werden. Die anabole Therapie erfolgt mit Romosozumab oder Teriparatid, jeweils gefolgt von einer Erhaltungstherapie mit einem Antiresorptivum. Eine primär antiresorptive Behandlung ist unverändert sinnvoll bei ausreichend erhaltener Knochenstruktur und hohem Verlust-/Frakturrisiko.

Individualisierte Langzeitkonzepte Leitliniengerechte individualisierte Langzeitkonzepte müssen dem persönlichen Risikoprofil und der Krankheitsaktivität gerecht werden. Behandlungsziele („treat to target“) sind die funktionelle Wiederherstellung auf das Niveau vor Fraktur(en) und die bestmögliche Reduktion des zukünftigen Frakturrisikos. Die Langzeittherapie besteht aus sinnvollen Sequenzen, eine lebenslange Therapie mit einem einzigen Medikament ist nicht durchführbar.

Abstract

The state of the art of osteoporosis management and treatment is being continuously refined according to recent progress in data availability, drug development and strategies as determined by health authorities. The recent approval of the sclerostin-antibody romosozumab as a novel first in class anabolic drug is another milestone that enriches our therapeutic portfolio. Neutralisation of the wnt-pathway inhibitor sclerostin by romosozumab leads to rapid stimulation of bone formation and a rise in bone mineral density that translates into robust > 70 % reduction of fracture risk at the lumbar spine. Already after one year of treatment romosozumab is stopped and followed by antiresorptive maintenance treatment. The indication for this strategy is severe osteoanabolic compounds can now be applied as a first line treatment without prior antiresorptive medication. The new data helped in alleviating restrictions by the authorities for first line use of anabolic strategies. Romosozumab and teriparatide represent two anabolic strategies that differ in their mode of action although the molecular mechanisms are partially overlapping. Teriparatide is primarily active as a remodeling agent whereas romosozumab exerts bone mass gains mainly via modeling. Differential therapeutic strategies throughout a patient “career” may take into account these differences as well as adverse effects and individual contraindications. Based on all our recent progress and achievement we can more and more individualize the long term management of osteoporosis over decades applying an individual “treat to target” strategy. Basically, osteoporosis is a chronic disease and has to be treated as such. If however for whatever reason treatment regimens using biologicals are being discontinued we have to be aware that such situations need to be stabilized using long-acting bisphosphonates to maintain the therapeutic success and avoid rapid bone loss and fracture risk

Schlüsselwörter

Osteoporose - anabole Therapie - Sklerostin-Antikörper - Langzeitmanagement

Key words

osteoporosis - anabolic treatment - sclerostin antibodies - long term management

Publication History

Article published online:
29 March 2021

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• Weitere Literatur beim Verfasser.