Rick Pope MPAS, PA-C, DFAAPA, CPAAPA, is an Author, Clinical Professor University of Bridgeport PA Institute, Sacred Heart University PA Program, Rheumatology PA (emeritus) Department of Rheumatology, Danbury Hospital, Danbury, CT and Founder and Past President, Society of PAs in Rheumatology.

Introduction

Happy New Year! Welcome back to MEDS eNews. For this first month issue of 2023, I got a chance to speak with Rick Pope MPAS, PA-C, DFAAPA, CPAAPA. I’ve wanted to catch up with Rick since his presentations at the recent MEDS Summit because they were so well received. So I asked him here about these topics and then some other critical aspects of MEDS care. Rick is an author and Clinical Professor at the University of Bridgeport PA Institute, Sacred Heart University PA Program, Rheumatology PA (emeritus) Department of Rheumatology, Danbury Hospital, in Connecticut, and Founder and Past President of the Society of PAs in Rheumatology. Rick is a very well-respected thought leader in the MEDS community, but he’s also a great example of how this MEDS community is such a supportive, connected group that does everything it can to bolster and lift up its members. We discuss pearls from his presentations, new advances in therapeutics—including testing, screening, and recent pharmacological advances for osteoporosis, the challenge of when your patient comes off denosumab, and more. Following the interview is our Rapid Fire segment!

If you missed it, you can access the recent MEDS Summit and register here for virtual access that fits your schedule. The best resource for the most up-to-date, clinically relevant information on treatment of diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease, it’s a one-stop shop to get you up to speed with CME!

Next month we will speak with Rick Pope, MPAS, PA-C, DFAAPA, CPAAPA. Thank you to Rick for his time here and as Medscape conference faculty! Please contact me at colleen@cmhadvisors.com with comments or suggestions. Thanks for reading! —Colleen Hutchinson

Rick Pope MPAS, PA-C, DFAAPA, CPAAPA Weighs In

Author, Clinical Professor University of Bridgeport PA Institute, Sacred Heart University PA program, Rheumatology PA (emeritus) Dept of Rheumatology, Danbury Hospital, Danbury, CT Founder and Past President Society of PAs in Rheumatology.

What are some pearls or takeaways you shared in your presentation in Session VII: Endocrine Part 2 on Part I Osteoporosis: Who We Screen, Who We Test, and Current Recommendations for Therapy at the Metabolic and Endocrine Disease Summit Fall?

Rick Pope: 1- There are medically approved easy and familiar medications that, when sequenced correctly, can dramatically improve bone density and fracture risk. 2- With the new drug pipeline tied off for the moment, we are learning now how to sequence medications especially for those in the high-risk categories for osteoporosis. Anabolics are now ready for prime time in this category with follow-on therapy with antiresorptives. Teriparatide, abaloparatide, and romosozumab have been studied with follow-on therapy with bisphosphonates and have shown clear superiority in preventing spine fractures, and significantly improving bone density over a three-year period.

Any pearls from your presentation, Part II: Case Studies in Osteoporosis?

Rick Pope:  1- Beware the wrist fracture. 2- Wrist fractures are sentinel events and should be considered a medical emergency. Workup and treatment going forward is critical as statistics show that wrist fractures are a warning signal for future fractures. BMD testing, basic lab work, and appropriate treatment for risk including patient education, and treatment with both lifestyle and medications if indicated, are critical with this common fracture.

What steps do you need to take now if your patient comes off denosumab?

Rick Pope: Stopping denosumab without a plan for follow-on therapy can lead to a significant increase in multiple vertebral fractures. The PI was changed to reflect this risk in 2017. What is very interesting is a new cell type that has been discovered called an “osteomorph.” These cells turn into active osteoclasts shortly after the first month from the last six-month injection. Multiple vertebral fractures occur as a result of these osteomorphs reactivating as osteoclasts. and thereby increase bone turnover and lead to fractures. Practitioners should embark on a clear understanding that once denosumab is started, it should not be stopped. However, a discussion of follow-on therapy is critical and, in most cases, should be a bisphosphonate.

What were some of the takeaways from the Session 8 Clinical Knowledge Session you facilitated with Scott Urquhart?

Rick Pope: Lots of questions came up about osteonecrosis of the jaw and atypical femoral fracture. The side effects are rare but more commonly seen with long-term bisphosphonate users and in those being treated for underlying malignancy with risk for metastatic bone disease. Takeaways included having a regular dental appointment prior to treatment and treating only those with highest risk of fracture with 10-year oral therapy or 6-year IV treatment. Moderate to high-risk patients should be treated up to 5 years with oral therapy and three years for IV treatment. Atypical femoral fractures are rare and can occur in the general population. Warning signs occur in 2/3 to ¾ of patients with a prodrome of hip pain and these complaints should be taken seriously. X-rays with attention to cortical thickening on both the lateral and medial sides of the cortex should be evaluated. Medication discontinued and careful close followup is critical.

Rapid Fire with Rick Pope:

Most critical new advance in my area of medicine:  Romosozumab for high-risk patients to start and then sequenced to denosumab or alendronate as a followup.

My mentor: Mike Lewiecki, MD, University of New Mexico Bone Health Tele-echo

Advice that’s helped in my career: My collaborating rheumatology MDs over a 30-year career

Best tool in my clinical arsenal: Physical exam and height measurement

What I wish the patient would remember: Selected exercises daily help keep bones strong. Balance and gait prescriptions should be used liberally.

Biggest challenge for me and my colleagues: Getting the general population to appreciate the significance of fractures as a risk for early demise. It is not just bad luck.

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