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Switching Meds- Osteoporosis
May 31, 2013

Thank you for your response it was a great help on making a decision to Stribild. I had a bone density test done showing low bone mineral, including osteoporosis. Can you give me some options on how I can treat this. I know there are different drugs in pill form and also intravenous form. I do lots of weigh training, cycling and running that suppost to helps my bones, I also take calcium and vitamin D. Can I get by with just training and supplements instead of having to go on drug treatment? Have you herd of a combination drug Teriparatide (Forteo) & Denosumab (Prolia) ? its been very successful in treating Osteoporosis.

Response from Dr. Young

Hello and thanks for posting.

Sorry to hear that you have osteoporosis. This condition of low bone mineral density affects upwards of 10% of the HIV population here in the US-- and appears to be related to increased risks of bone fractures.

You've summarized much about bone health/disease care- getting weight bearing exercise (by the way, cycling doesn't fully count in this list), having a diet with adequate vitamin D and calcium. In addition, quiting tobacco and limiting caffeine is likely helpful. In my patients with baseline osteoporosis, I'll also consider whether tenofovir-containing treatment is the most appropriate, or if there are suitable alternatives; tenofovir treatment is associated with greater initial loss of bone mineral density in the first year of treatment.

If your bone density is not severe (ie., just minimally osteoporotic, with a T-score around -2.5), then I might be persuaded to delay on pharmacological interventions and see if all the other things you're doing improves the density (and fracture risk). A repeat scan in 1-2 years will tell you if you're heading in the right direction. On the other hand, if you have additional risks (like a strong family history, history of broken bones, or certain medication use- like steroids), your risks might be greater- and thus, the threshold for pharmacological treatment lower.

The bulk of the data on treating bone density problems in positives is with alendronate (Fosamax), where clinical studies show both effectiveness and safety. There are additional small studies that suggest that other treatments (and very recently, combined therapies that you've listed) are perhaps more effective- it's just that there's less data. The Lancet publication on teriparatide and denosumab has additional information about the combination.

Overall, this is a fast-moving field with growing concern in the HIV treatment community, especially as a greater number of people living with HIV are reaching mid-life (or over the age of 50). For more information about osteoporosis and HIV, check out myhivclinic.org's osteoporosis pages.

I hope that helps, BY



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