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Clinical Cases in mineral and bone metabolism

Pain from osteoporotic fractures: rationale of therapeutic options

Mini-Review, 36 - 40
doi: 10.11138/ccmbm/2018.15.1.036
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Abstract
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Bone fractures are the most important cause of severe acute pain in osteoporosis, which is later often followed by chronic musculoskeletal pain due to dorsal kyphosis, exaggerated lordosis or compression of nerve roots or spinal cord. The functional stress on spinal muscles and ligaments results in the development of chronic back pain and impaired mobility. Injured structures in the lumber spine can also produce referred pain or a true radicular pain.
Drugs against osteoporosis may have some analgesic effects, as has been shown for denosumab or bisphosphonates like pamidronate. Similar results have been obtained with calcitonin, which is no longer available for the treatment of osteoporosis. Selective estrogen receptor modulators like raloxifene and the anabolic drug teriparatide can also reduce osteoporotic pain and augment fracture healing.
The vicious circle of osteoporotic pain, immobility, muscle atrophy and enhanced osteoporosis has to be interrupted by an effective multimodal pain management. Beside the treatment of osteoporosis and fractures, analgesic drugs play a major role in restoring physical functioning and mobility. The mainstay in pain management of osteoporotic fractures is the WHO 3-step analgesic ladder with the combined use of non-opioids (NSAIDs, paracetamol) with weak opioids like tramadol for mild to moderate pain, or strong opioids like morphine, hydromorphone, oxycodone, buprenorphine, fentanyl or tapentadol for moderate to severe pain. The combination of nonopioids with oral controlled release (CR) strong opioids or prolonged release (PR) tapentadol provides excellent analgesia even in severe pain from osteoporotic fractures. This is also true for transdermal therapeutic systems containing fentanyl or buprenorphine (skin patches).
There are differences in the relative fracture risk of opioids, which is highest with fentanyl and lowest with buprenorphine. Some opioids influence the endocrine system, particularly the sex hormones, and lowered testosterone and estrogen levels finally reduce bone
density. Tapentadol is an exception, which acts simultaneously as a μ-opioid receptor agonist (MOR) and a noradrenalin reuptake inhibitor (NRI). It has minor effects on the endocrine system and sex hormones and should therefore be favored for long-term treatment of osteoporosis pain. The synergism between its two analgesic mechanisms improves analgesia and reduces adverse events.
In conclusion, the standard treatment of acute and chronic pain after osteoporotic fracture is a multimodal analgesic therapy including non-opioids, opioids, mobilization and rehabilitation. Opioids with minor effects on
the endocrine system and bone density, such as buprenorphine or tapentadol, should be preferred for long-term pain management in these patients.

Vol. XV (No. 2) 2018 May - August

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