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Osteoporosis treatment after AFF and ONJ
Dr. PD E Biver, Geneva
Friday, May 13, 2022 · 3:55 p.m. · 24m 54s
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00:00:00
mm good afternoon and thank you very much uh for the invitation yes
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i've been asked to cover the topic of uh oh still poses treatment after
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at typical thermal fractures and joe was tunic was this so as you imagine
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this is not a an easy task and uh i'm going to try to discuss with you uh uh these aspects
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so but we are talking of the tool main side effects
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of long term a treatment with auntie was up to draw a dessert
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uh and i will focus my presentation just owns you was to put it
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stating not zoo on courage exacting especially for the joes tunic was this
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but i just would like to remind you hear that um the the main risk
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factor for a typical humour factor it's long term treatment with auntie was opted works
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uh that that that we have is generally patients wheeze eight to ten years of treatment we don't use opted rates
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for joe still because these it's not this cell is the duration of the treatment but
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it's also the doors and that's why it's mainly observed in the on call logic settings
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and it's high and punitive those ease of onto was up to dress with just this means that
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in the field of course to produce we we generally see this way of
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side effects also in patients receiving longterm treatment was onto was up to rights
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i also show you hear some a. p. due to call data to show you that
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says these are really rare events globally let's
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say one to a one hundred casey sparrow
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a one hundred thousand the patients bill you uh in our feet
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so no exact as these rare side effect of you in patients
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with it's a long term treatment with auntie was up to drugs
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this means that he sees patients received longterm
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treatments this is probably because they are at high
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risk of bone fragility and it's the reason why you continue this treatment for a long time
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we may discuss these but that what was of the patients and
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we may be concerned with the future we skull fracture of these patients
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so how to deal with these questions of course to put this treatment
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after these ravens i choose to discuss this point according to three points
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the first one is do we have that are on the risk
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of fracture after these events because these patients already had long term free
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the second point is if we consider was to put
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the treatments what are the bottom side effect of this treatment
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all the outcome of these cadence i mean on the healing of
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a typical somewhat factor or angie and also potentially the risk of recurrence
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and just so point is that if we consider treatment do you have it ends
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that out drugs will be effective to prevent
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future factor in the specific context of patients
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i'm not finally the classical patients uh with osteoporosis and naive or any treatment
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so i will try to cover with you the data we have on this
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and uh i will begin with a typical to moral fractured first
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then we will move to are still on the causes of the joe
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and i will finish to some specific considerations that may be applied to both of these uh a complication
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so let's begin with a typical to mark fletcher and the risk of new fracture
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after not to because someone faction and we had the opportunity in geneva to follow
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a fifty five of all patients with a typical similar fracture for i mean for the web of sixty eight
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and as you can see she at least found that
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most and one patients on to sustain a new fragility fracture
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within the year after that typically more fracture major loss to critique fracture
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and the major each of these patients just ain't two or three fractures
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and when you compare the incidence of fracture uh
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compared to patients match for h. b. a mac
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and to sustain a major or stupid fracture and we should just that we feel will major stupid factor
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as a classical risk of imminent reese facto reese factual risk as you know we'll set
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uh see now even higher risk of new or still put it fracture
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after and the typical from art factor in these patients suggesting that despite receiving
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seven eight or ten years up onto was up to browse these patients with
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a typical humour factor remain at very high and imminent risk of new fact
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and when we looked at the predictors of new for g. t. factor in these patients zoos
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made one was the level of b. m. d. and they that that you observed as the time of the
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at typical femoral fracture we did not accept any also
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a respectable and the interesting observation we had also is that
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we had some patients to continue onto resulted but
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after the typical remote factor and some who does continue
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and the fact that we continue or not to treatment was not associated
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with virtual fighter this is just an observation but one point to plug in
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the second point is okay that was our high fiscal factor
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so should i consider to continue onto that you draw uh
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to move to an an oblique a drought and what will be easy effect
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on the feeling of that to the consumer factor or the risk of compliment to a typical summer fact
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i will just show you some that ah we can discuss on this was when they tend to be correct tied
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i just say she is that we have absolutely no that are regarding the nose remark regarding right that's the same
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i uh and i just want to mention that regarding well most of them have as its uh the topic now
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in the frame and arched studies there was only a few a typical to mark factor and the whole crew
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mainly after the one year of treatments uh during the phase of onto was upkeep
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so let's begin with this was when it's an she if i we
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bought the cases of one of our cases so classical complete at the because
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the more factual in two thousand so t. m. in this lady and
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she continued bottlenecks and you can see that five years later she has to
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she has two incomplete at the because the more factor on the controller tight side
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and this is clearly illustrated what what we know is
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that i go back to our patients fifty five cases
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uh in in geneva and we had thirty five percent of the
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these patients who had compliment to al a typical to mark factor
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the major we t. was at the same time of the first uh to
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because remote factor but some of them developed these fracture later during the for like
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and when you look at the predict those to develop called targeted at a typical from artifacts so
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what we found is that continuation of onto was up to drugs
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after the index at typical for our factor was associated with these weeks
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so suggesting that continuing and onto that you brought after on a typical to more fracture
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is not a good option and when you look at the values will use all consensus on the topic
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there is a consensus to say that for patients with the comfy and
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incomplete at typical from our factor this was when it should be discontinued
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of course they say that imagine that you have be that i i
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typical k-mart fracture that you see where surgically managed always uh nailing militarily
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you may say okay now they don't have any reason to develop a
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new a typical summer factor i would say at least on the fear
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and in this case maybe we may we concede uh this was a
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nato the news maybe in case of high risk of bonsai g. t.
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i'm not convinced of that and we will discuss this at the end but
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keep this in mind and in any case we don't have any data showing
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that if we continues reading these contacts we we improve the risk of fracture in these patients
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i just want to mention she is that in the cases of at
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the because they want factor option when in patients after you know the
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mob if you discontinue the nose you might you would have to deal
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with the potential rebound of the ball remote leaning and too many disease
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and put aside in these cases we may consider short course of peaceful soul mates and to monitor
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all the bone was option mark uh to deal with all these aspects now we got a tele apartheid
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we know all that patients with a typical to mark
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factor at significantly higher risk of the lady heating nonunion
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and frequently need secondary surgical procedures compared with patients with typical thermal fracture
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so in this context data type that's been used in
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mainly case we bought of up to also bachelor studies
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we the object is to promote the feeling of the surgery and
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of the initial factor uh or if i actually of the incomplete fracture
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you have your table some allies in the data out also motion align case report
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well radiological feeling of the at the because immoral fracture after to the part that that
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and nobody what you see if you look at the rate of healing after six o. moans all one year
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you see that yes globally maybe there is a trend
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that patients treated with the reaper tied have a small bit
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if it's on the healing compared to lose who did not
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receive that again this is not randomised control trials uh uh
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what actually was more single here but what is interesting for us
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it's this case all eight of incomplete active because from what factor
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in which you will not decide to do the surgery isn't a lean and
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your afraid that they develop a complete fracture uh within the next month so you
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and when you look at that the case report looking at that show a very
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low weight of healing in this population of incomplete to because remote fractures so globally
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the message we have is that yes maybe to repair that might result
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in faster healing you of search it surgically treated to because what factor
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but there is no evidence for benefits in non surgically
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treaty income pick a typical german faction and these observations
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ah comfy and in the first double
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blind placebo controlled one demise trial who focused
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on telly but i'd in incomplete at the because um well fractures this is a ten agenda uh studies that
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which is not yet published but the first results of these staff trial
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where i presented to usable at i. b. m. yeah and you see that
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in these thirty four women who had or incomplete a typical thermal fracture
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you all received this forceful mates exposure we use your duration mean duration of ten years
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on values outcomes including the war marks call
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so i'm past what so what outcomes without being a name the quality of
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life some outcomes regarding the b. a. n. d.'s and outcomes regarding the ideological healing
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there was absolutely no benefit of the prototype compared to placebo in the study
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so consuming that you you don't have evidence that we help patients on this aspect with the report
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just one observations in the country in order to study
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there was no casey some progress to complete a fracture insisted
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we are waiting the publication and problem probably a a more data and
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well let's do the same with joe's tunic was nice and what is
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the risk of fracture after joe tunic was is and again here i want
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to focus on most of the patients but basically we don't have any
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data and i sink that clearly this is the on it already news populations
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we is put on charlie rhys factor of hybrid fragility because for example we know that
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cost a cost or use is also a respectable forgotten because these tobacco alcohol and so on so
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or the fact always fragility and this probably deep depend
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of the patients itself and it has to be individualised
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and i would say that we may discuss these that's probably the risk of fracture should be assessed
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based on the clinical with factor of the patients and again of the b. m. d.
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i did not mention the facts here because honestly i'm not convinced that facts clearly
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evaluate or future risk of fracture in these patients with long term treatment with this was when it or so
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now what is about uh the effects of our drugs
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all the schools of our joe still it was nice
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uh just to keep in mind i mentioned he is the right of joe still because he's in the was
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still put take studies uh uh using out right then you can see that this is a right a rare events
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uh between a zero point zero two two zero point
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zero five percent it in these because when it's studies
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um it there willow asked the even ten years of the no
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two mad because it's only zero point three percent after ten years
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and again regarding what was your mother and i would say the
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sequence was mad then onto adoptive drags it was within the same order
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so should we continue or discontinue beast was when it's a after a joint only crazies
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for this case uh we don't have seen it dozens
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sad discontinuing the onto adoptive drugs we improve the schools
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of the jaw still nicholas when it happens whatever you do
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finally this will not change the course of the of the
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disease and nobody is the recommendation say is that uh the administration
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of the beast was an act of the d. map
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maybe these felt at the discretion of the treating physician incontinent
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junction with discussion with the patients and the whole i'd have to provide a okay we are that we had with that
00:14:59
but um uh another recent study show that the drug holidays is not associated with the outcome
00:15:05
of more c. v. s. uh joe's tunic with this we require surgery and you don't need to
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wait a drag holy day to consider the surgery of the georgian because he's it does not change
00:15:17
as the outcome rather than doing the surgery and and the
00:15:20
optimal management at uh at the the the beginning them so
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it's more different pattern regarding the a typical summer factor regarding the onto adoptee products
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now what about the early part tied shall make the
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observation i'd case reports studies should just seems that telepathic
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may promote the feeling of the job was the only
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qualities and he if we have a placebo controlled randomised trial
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who demonstrated that the use of the rubber tied we accelerate the healing
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of the joystick with these in this control study so this is probably one of them might
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must uh basically thence we have in this topic in favour of the repair tied in this complex
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so this is where we ha and no i come back
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to these two sides effect just to discuss some some consideration
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so of course we are now convinced that many of these
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patients remain at high risk of fracture after these side effects
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so
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always a useful to remind that it's important to take care
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to the costume interact with vitamin d. to the values nutritional aspects
00:16:37
and two for prevention and promotion of physical activity ah as
00:16:40
far as possible this is always important to optimise these buttons now
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knowing that are at risk of don't for g. t. how we knew manageable for each of these patients
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should we consider a beast was when it's despite all was what i mentioned uh uh already uh uh idea
00:16:59
i would like to remind you that most of these
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patients received more than save and eight nine years of treatment
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and we perfect even though that after this
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duration of treatment we do not expect any additional
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gain on bone mineral density due to the pedal effects that we also with this was when it's
00:17:21
so even though i don't have that are showing these contacts what i expect based on the mechanism of action
00:17:27
we have to keep this in mind that i'm not tools that continuing to be so soon it will
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be significantly increase might be in d. and my factories
00:17:36
ford did not smart the case might be potentially different
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the second point regarding terry apartheid and this was discussed this morning we spent a line that
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is that we know that the i'm not logic effect of to reply tied is low uh
00:17:52
after a long term treatment hopefully treatment with onto receptive products and this was when it's
00:17:58
and we know that we have greater be in the increase in naive patients
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or in patients treated with um the sports when it's but with relatively low affinity
00:18:10
and we even have some data showing that the sequence of this was when it's to to reply
00:18:16
to add may even at least in the shop there decree the bone mineral density at the hip
00:18:24
and this is particularly relevant in the sequence of the news you map to to reply tight because as you know we should
00:18:31
discontinue the nose map you have the rebound of the boundary marlene
00:18:35
and that apartheid also increase the border marlene so you may expect
00:18:39
further a decrease of the bone mineral density that's why one of the question we ha but this
00:18:46
is an open question is that if we consider terry part that that may be interesting in some context
00:18:52
should we maybe consider a combination with an auntie was up to drugs
00:18:57
and my maybe this might be the best option especially after the nosy mob uh in these patients
00:19:04
but this is just some uh questions uh open uh and to into keeping
00:19:11
so to summarise um i think that's that's what
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we can uh say today uh regarding the topic
00:19:20
we got the infraction research we know that the risk
00:19:23
is particularly high after on a typical from our fracture
00:19:27
and is mainly driven by the little of bone mineral
00:19:30
density you have at the time of the typical family factor
00:19:35
after and that and uh joe tunic was these honestly it's patient dependent
00:19:40
and i encourage you to look at the exact the clinical was factor
00:19:44
regarding the use of onto adoptive drives we know that um and uh after not to because
00:19:51
from our factor you increase the risk of competitive i typically more factor with onto resulted right
00:19:57
you'd it's not demonstrated that the continuation is the
00:20:01
data use in the cases of joe's tunic was this
00:20:04
and regarding is a prevention of future of two parts the cracked or we have no that
00:20:11
concerning terry apartheid we can say that potentially you have
00:20:15
a faster healing of surgically treated a typical german fracture
00:20:20
but the results regarding incomplete a typical from our factor out negative
00:20:25
with uh well one controller a randomised control trial
00:20:30
after at the uh joe till could make with these we have data showing that you promote the healing
00:20:35
of the joystick was this we still apartheid and again concerning most of the fracture we have no that
00:20:43
so that's where we ha and of course no this is open for discussion that
00:20:48
the t. v. set i seen that this should be an individual that lies a discussion
00:20:53
uh and with a monitoring of the b. a. n. d.'s a bottle markup probably had full
00:20:58
in this context uh but this is not a a new seeking the crustaceans thank you very much
00:21:08
thank you very much admired for his excellent presentation over challenging topic um all the questions
00:21:17
such a he's closer and you can run fast enough a minute
00:21:25
thank you very much indeed very complex topic so you see in the
00:21:29
in the yeah for a study from jail with that you publish these uh it was a uh you you
00:21:36
clearly show that after the f. f. where do you
00:21:39
stop we'll continue to drug no difference on fracture risk
00:21:45
but we know all that when we stop don't resort to the
00:21:49
reserve component or fracture decreases very fast right you have you know
00:21:53
a few more yeah so it seems to me that that is
00:21:56
clear right a. f. s. means stop don't result could absolutely or
00:22:02
that's why there's a consensus i mentioned was onto up to that point the consensus is you you we have to stop this one yeah
00:22:09
yes please not question no there's another question in the meanwhile for how long do
00:22:16
treat with paper applied visitation who had
00:22:19
when g. is that it's limited to sometime
00:22:25
um i think we have don't have here that ah is is the outcome is
00:22:30
to optimism the heating of the i think that a few moments or even weeks
00:22:36
so maybe enough now now if we consider patients with high risk of one for duty uh maybe we'll continue
00:22:43
uh for a longer period because study was one forty eight weeks yes yeah the commercial okay this is
00:22:50
good manners or your nice presentation so i take that back piece if you had that patients with
00:22:57
a typical ten last factor n. a. is on the wall she sounded the nelson had three things
00:23:03
hi allegedly rediscover bound affects a and the risk of getting at
00:23:08
this fascinates so increasing but then neither is common additive in fact
00:23:14
well so the way cases we had on the nose tomorrow
00:23:19
we manages them by continuing to those in math and adding to read about that
00:23:26
and and we and we follow and we follow the the bond market we for
00:23:30
those are the symptoms it also depends is i had a comparative allocating or not
00:23:36
but um this is one option the second option is also
00:23:40
depends because some of these patients may have that confirm affected
00:23:44
under the nose amount but receive before the no zoom out long value out of
00:23:48
the source and it's and in this case you do not expect that a huge reborn
00:23:53
but i would say that this is not complain because we had one case like this and we did not expecting rebound and
00:23:59
finally the patient kind of a you would rebound and we had
00:24:02
to go back to the the map pressed every part that so
00:24:07
this is clearly a case by case that age and on the other way what i i'm doing in that i
00:24:12
will be more keen to use oral pieces when it's to maintain this it takes levels in between i would say
00:24:19
uh and i will be made less stringent in the target of cities
00:24:24
but to avoid a a huge depression of the bone remote leans that may promote a a new at typical firmer factor
00:24:31
and meanwhile to avoid the let's say the they go up to a very high one remote wedding
00:24:37
and and follows as also with wood and thank you very much i wonder is there any other question
00:24:44
otherwise i would like to thank you and would like to close the session and
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