April 15, 2022
ملاحظة: كُتِب هذا المحتوى قبل جائحة فيروس كورونا المستجد (كوفيد-19)، ولا يوضح البروتوكولات المناسبة للتعامل مع الجائحة. يرجى اتباع جميع الإرشادات التي توصي بها مراكز مكافحة الأمراض والوقاية منها بشأن ارتداء الكمامات والتباعد الاجتماعي.
The COVID-19 pandemic has created unprecedented challenges to health care delivery across numerous domains. Like many other chronic conditions, the care for patients with osteoporosis was also affected.
Bart L. Clarke, M.D., and Matthew T. Drake, M.D., Ph.D., Endocrinology, Diabetes, Metabolism, and Nutrition, at Mayo Clinic in Rochester, Minnesota, along with colleagues from other institutions, published an international perspective in the Journal of Bone and Mineral Research in June 2020, early in the pandemic, to guide clinical practice.
Dr. Clarke explains: "Delaying the administration of certain osteoporosis drugs can have ominous consequences, such as loss of bone mass, increase in bone turnover and increase in fracture risk. Because there is paucity of data to provide evidence-based clinical recommendations, we formed an expert consensus on best practices.
"For example, to minimize patient exposure at phlebotomy centers, we recommended that patients considering intravenous bisphosphonate, denosumab or both with normal pre-treatment laboratory studies within the preceding year need not have updated lab work, unless deemed necessary by clinical judgment. The exceptions were patients with fluctuating renal function and those at higher risk of developing hypocalcemia.
"Telemedicine allowed the initiation of osteoporosis therapy, particularly oral therapies, in high-risk patients, such as those who recently sustained an osteoporotic fragility fracture or patients on chronic high-dose glucocorticoids. We provided reassurance that patients taking osteoporosis therapy should continue doing so, as there is no evidence that being on osteoporosis therapy increases the risk or severity of COVID-19 infection or alters its disease course in any way. Because COVID-19 infection is associated with an increased risk of hypercoagulable complications, we did exercise caution in patients on estrogen and raloxifene, which can both modestly increase thrombotic risk."
Dr. Drake notes: "We also addressed how to deliver non-self-administered parenteral osteoporosis medicines. In this context, home delivery and administration or drive-through administration of denosumab or romosozumab were considered, recognizing that there were logistical and medico-legal considerations. We acknowledged that individual health care centers were in the best position to determine what the logistical challenges were and what solutions were possible.
"Delay in timely denosumab therapy is associated with an increased risk of rebound-associated high bone turnover, rapid bone loss within one year and an increase in the risk of the development of multiple vertebral fractures. For patients in whom continued treatment with denosumab was not feasible within seven months of the most recent prior denosumab injection, we recommended a temporary transition to oral bisphosphonate such as weekly alendronate.
"In patients with upper gastrointestinal symptoms, we recommended consideration of monthly ibandronate or weekly or monthly risedronate because of fewer reported upper gastrointestinal side effects. In patients with estimated glomerular filtration rate under 30 mL/min, we suggested that lower dose oral bisphosphonate could be cautiously considered, although this is off-label use. We were clear to point out that there was no published evidence to support off-label regimens and that a clinical decision based on a risk-benefit analysis should be made. We also provided recommendation where delays in self-administered anabolic therapy or romosozumab were anticipated."
Dr. Clarke concludes: "The last 18 months have provided an opportunity to come up with creative clinical solutions as we seek to balance the benefits of uninterrupted treatment with the risks of exposure to the virus. The lessons we have learned should help evolve clinical practice through this pandemic and beyond."
For more information
Yu EW, et al. Osteoporosis management in the era of COVID-19. Journal of Bone and Mineral Research. 2020;35:1009.
Refer a patient to Mayo Clinic.