Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, which causes bone fragility and leads to a consequent increase in fracture risk. In the last 20 years, the prevention of fragility fractures has improved with the development of screening by bone densitometry and access to effective medications. The identification of individuals at risk for fracture and initiation of appropriate medication though, is low and opportunities are often missed. According to Mitchell in Current Osteoporosis Reports in 2013, less than 35% of hip fracture patients receive pharmacologic treatment within 6 months of their fracture. After one fragility fracture, the risk of a subsequent fracture is increased significantly and treatment is warranted. One of the newer strategies for identifying patients at risk is the development of the Fracture Liason Service (FLS), which is a dedicated program to identify and treat patients with recent fragility fracture, often in hospital settings. This is a multidisciplinary system approach that provides easy access to osteoporosis care. Osteoporosis is the most common bone disorder that affects humans. The risk of hip fracture doubles for every 5 to 6 years of increase in age from 65 to 85. Vertebral fractures can lead to consequences including acute and chronic pain, impaired function and increased morbidity and mortality and increased fracture risk. Hip fractures can lead to loss of ambulatory status; loss of independence increased morbidity and mortality and increased fracture risk. Who should be screened?
National Osteoporosis Foundation (NOF) recommends screening for:
–Women aged ?65 years and men aged ?70 years, regardless of risk factors
–Postmenopausal and menopausal transitioning women and men aged 50 to 69
years with clinical risk factors for fracture
–Postmenopausal women and men aged >50 years who have had an adult-age
–Adults with a condition or taking a medication associated with low bone mass or
Dual-energy x-ray absorptiometry (DXA) is the current standard for measuring
bone mineral density (BMD)
North American Menopause Society Guidelines for screening (NAMS): (North
American Menopause Society. Menopause. 2010;17(1):23-54.)
–All women ?65 years, regardless of clinical risk factors
–Postmenopausal women with medical causes of bone loss
–Postmenopausal women ?50 years with additional risk factors
–Postmenopausal women with a fragility fracture
US Preventive Services Task Force (USPSTF):
–Recommendations currently under review Risk Factors for osteoporosis include:
–Low body mass index (BMI)
–Poor calcium intake
–Lifestyle (e.g., smoking, caffeine consumption >300 m
Chronic kidney disease
–Oral glucocorticoids (?5 mg/d of prednisone for >3 months)
–Systemic lupus erythematous
–Conditions associated with malabsorption (e.g., celiac disease, inflammatory bowel
–Chronic obstructive pulmonary disorder
And medications including:
Interpreting fracture risk from screening by bone density and FRAX
Bone Densitometry is used to determine the bone density along a continuum from normal to mild and moderate low bone mass and osteoporosis. Treatment parameters are determined from the bone mass, reported as the T-score. It is known that additionally, a significant number of people will fracture with T-scores between normal (-1.0) and osteoporosis (-2.5) and it is important to identify those people at high risk for fracture, who do not yet have osteoporosis. The use of a calculation with a data set and patient demographics is made with the FRAX Calculator to determine their 10 year fracture risk. The patient demographics including current smoking, family history, history of adult fracture and age and bone density at the hip are entered into a computer program and the 10 year risk is calculated. Preventative medication is considered when the 10 year fracture risk is 20% or greater for major osteoporotic fracture and 3% or greater for hip fracture. The FRAX calculator for gauging 10 year fracture probability is available at:
Who should be treated?
Current guidelines recommend treating patients with osteoporosis on bone densitometry or with a history of a prior hip or spine fracture. The other area for significant improvement in fracture prevention is the identification and treatment of patients who are not yet osteoporotic, but have a high fracture risk with the FRAX risk assessment tool. This means that patients with osteoporosis by T-score should be treated, but patients who have mild and moderate loss of bone mass should additionally be evaluated for their 10 year fracture risk by the FRAX calculation.
When it is determined that treatment is indicated in an osteoporotic patient or when the 10 year fracture risk is high, pharmacologic options include: antiresorptive agents, rank ligand inhibitors and anabolic agents. The National Osteoporosis Foundation, Clinicians Guide suggests that no pharmacologic therapy should be considered indefinite in duration and after three to five years of a treatment period; a comprehensive risk assessment should be performed. There is no uniform recommendation that applies to all patients and duration decisions need to be individualized.
New concerns include those of long term use of bisphosphonate therapy that may lead to rare complications of osteonecrosis of the jaw and atypical subtrochanteric fracture. Drug holidays after 3 to 5 years of use may be indicated in patients without high fracture risk at that point. New data suggests that the rank ligand inhibitor should not be discontinued without additional therapy to prevent rapid onset of vertebral fractures. Drug holidays are not indicated for patients on rank ligand inhibitors.
Clinicians are in a position to improve assessment and treatment of patients with increased fracture risk. Non-pharmacologic therapies are also indicated with assessment of fall risk, balance issues and encouraging exercise and mobility activities. Recommend bone density testing when appropriate; utilize FRAX to find high risk fracture patients and initiate therapy to prevent subsequent fractures in patients with a previous hip or spine fracture.