As South Korea enters a super-aged society, the importance of long-term management in osteoporosis treatment is being emphasized.

During this process, the bisphosphonate class of drugs, demonstrating long-term evidence and sustained efficacy, is once again becoming the key treatment strategy.

DailyPharm met with Professor Beom-jun Kim of the Department of Endocrinology and Metabolism at Seoul Asan Hospital, to discuss the changing landscape and future challenges of osteoporosis treatment.

"Osteoporosis cases is increasing...prevention before fracture is crucial"

South Korea is one of the world's fastest-aging nations. With the elderly population rapidly increasing, the importance of osteoporosis management and government attention have both grown.

In particular, the rise in osteoporosis cases in South Korea is attributed to rapid aging and increased diagnosis rates.

Professor Kim explained, "As the elderly population rapidly increased, government attention rose, and this year, osteoporosis screening in general health check-ups was expanded to include women aged 60 and older," and added, "With early prevention and diagnosis underway, the number of patients is also increasing."

Osteoporosis is a disease characterized by porous bones. Since it typically presents no specific symptoms before a fracture occurs, it is easily overlooked by both patients and physicians.

However, as bone strength naturally declines by about 2% annually with age, the risk of fracture increases. Therefore, continuous management is emphasized, treating osteoporosis as a chronic disease requiring lifelong care, similar to hypertension or hyperlipidemia.

He stated, "Spinal and hip fractures not only severely diminish the quality of life due to pain, deformity, and mobility impairment, but hip fractures, in particular, carry a mortality rate of about 20%. Preventing fractures before they occur is particularly important, more so than treating them after one."

"Fosamax, a drug with 30 years of evidence...sustained efficacy of oral therapy is gaining attention"

To effectively treat osteoporosis, it is essential first to evaluate the patient's fracture risk and prescribe the appropriate medication.

According to Professor Kim, various factors are considered, including bone mineral density (BMD), T-score, age, weight, current medications, and family history. Generally, patients with a T-score below -2.5 are diagnosed with osteoporosis and categorized as high-risk for fracture. Bisphosphonate agents, including Fosamax, are globally recommended as the first-line treatment for these patients.

The major bisphosphonate, Fosamax (alendronate sodium), celebrates its 30th anniversary this year since its U.S. FDA approval in 1995. It was introduced in Korea in 1998.

Professor Kim explained, "The fact that we are still talking about Fosamax after three decades indicates its reliability." He added, "Its preventive effect has been confirmed across various sites, including vertebrae, non-vertebrae, and hip, establishing it as a first-line treatment for high-risk patients in both domestic and international guidelines."

He also mentioned the unique advantage of Fosamax as a once-weekly oral drug in the osteoporosis treatment landscape, where injectable drugs are commonly used.

Professor Kim pointed out, "According to the Korean Society for Bone and Mineral Research fact sheet, only 73.9% of women and 66.7% of men maintain treatment for a full year after starting medication. For injectables, discontinuing treatment can rapidly increase the risk of multiple vertebral fractures."

He added, "In contrast, Fosamax is deposited in the bone and maintains its therapeutic effect for a certain period." He emphasized that this feature, where the fracture-prevention effect persists for a period even after discontinuation, is an advantage in the Korean context, where treatment persistence is often low.

"The last in sequential therapy...need to improve access for patients at ultra-high-risk"

Professor Kim stressed that the concept of sequential therapy is becoming crucial, as osteoporosis treatment is a long-term strategy rather than a short-term prescription.

He said, "Considering the 100-year lifespan, continuously using a single drug is impractical. Therefore, a strategy of sequentially using multiple treatments, similar to hypertension or diabetes, is necessary," And added, "While Fosamax is recommended as a first-line treatment, its advantage as a 'closer' in the context of sequential therapy is gaining attention."

Professor Kim also said, "In the 'finishing stage' after reaching the osteoporosis treatment goal, Fosamax has the advantage of maintaining its efficacy in the bone, preventing rapid deterioration of the patient's condition." He added, "Regardless of the initial drug used, treatment must ultimately conclude with a bisphosphonate agent. We believe Fosamax's role in sequential therapy will only grow as new drugs increase."

He also evaluated the expansion of reimbursement criteria for osteoporosis treatment last year as a meaningful change.

He said, "Previously, patients had to stop treatment coverage if their T-score went above -2.5, even if they wished to continue. Now, the maximum period for continued treatment has been extended up to two years, even at a T-score of -2.0, which is positive for securing treatment continuity."

Professor Kim pointed out the institutional need to lift restrictions on the treatment sequence for ultra-high-risk patients and advised against avoiding treatment due to concerns about adverse reactions.

Professor Kim said, "Globally, the recommended strategy is first to use bone formation promoters (anabolic agents) followed by anti-resorptive agents for maintenance. However, due to current domestic reimbursement criteria, we must apply this in reverse," and suggested, "The treatment sequence needs to be improved, at least for the ultra-high-risk group."

Finally, Professor Kim said, "Although fear of adverse reactions is one reason for hesitation, concerns like 'jawbone necrosis' are actually very rare," and added, "The incidence in South Korea is around 4 per 10,000 people (0.04%), while the risk of fracture is a thousand times higher. Avoiding treatment due to a rare risk is like not wearing a seatbelt."