Commentary

Managing osteoporosis: Challenges and strategies

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ABSTRACTMany patients at high risk of fracture are not being identified and treated, and many of those who start treatment do not take it correctly or long enough to lower their risk. This paper is a review of unmet needs in the management of osteoporosis and strategies to improve clinical outcomes.

KEY POINTS

  • Osteoporosis is underdiagnosed. Patients discharged from the hospital after hip fractures are commonly not diagnosed with or treated for osteoporosis although the risk of future fractures is very high.
  • The Fracture Risk Assessment Tool (FRAX) estimates the 10-year probability of fracture on the basis of clinical risk factors for fracture and the bone mineral density of the femoral neck. The combination of bone mineral density and clinical risk factors predicts fracture risk better than either alone.
  • A drug holiday, for 1 year or perhaps longer, may be considered for patients on alendronate (Fosamax) who are no longer at high risk of fracture. On the other hand, given the evidence of increased risk of clinical vertebral fracture and hip fracture after bisphosphonates are discontinued, a drug holiday is probably not a reasonable choice in patients at high risk of fracture.
  • Patient education and regular contact with a health care provider may improve compliance and persistence with therapy.


 

References

Osteoporosis is underdiagnosed and undertreated,1 even though it is common and causes serious problems, and even though effective treatments are available. The US Surgeon General has challenged the health care profession to close “the gap between clinical knowledge and its application in the community.”2

This review describes current shortcomings in the care of patients with osteoporosis and suggests strategies for health care providers to improve clinical outcomes.

COMMON AND SERIOUS

Approximately 44 million American men and women, representing 55% of the population age 50 and over, have osteoporosis or low bone density that can lead to fractures.2 An estimated 2 million osteoporosis-related fractures were reported in the United States in 2005, with a direct health care cost of about $17 billion.3 By 2025, more than 3 million osteoporosis-related fractures per year are expected, with an annual cost of more than $25 billion.3

Fractures of the spine and hip are associated with chronic pain, deformity, depression, disability, and death. About 50% of patients with a hip fracture are left permanently unable to walk without assistance, and 25% require long-term care.4 The death rate 5 years after a hip fracture or a clinical vertebral fracture is about 20% higher than expected.5

DIAGNOSING OSTEOPOROSIS BEFORE A FRACTURE OCCURS

World Health Organization classification

The World Health Organization6 classifies bone mineral density on the basis of the T-score, ie, the difference, in standard deviations, between the patient’s bone mineral density, measured by dual-energy x-ray absorptiometry (DXA), and the mean bone mineral density of a young adult reference population:

  • Normal (a T-score of −1.0 or higher)
  • Osteopenia (a T-score of less than −1.0 but higher than −2.5)
  • Osteoporosis (a T-score of −2.5 or less)
  • Severe osteoporosis (a T-score of −2.5 or less with a fragility fracture).

The International Society for Clinical Densitometry has established indications for bone density measurement, quality control, acquisition, analysis, interpretation, reporting, and nomenclature.7 The Society states, for example, that bone mineral density may be classified according to the lowest T-score of the lumbar spine, total hip, femoral neck, or distal one-third (33%) radius (if measured), using a white female reference database in women and a white male reference database in men.

Why test bone mineral density?

Bone density testing allows a physician to diagnose osteoporosis before a fracture occurs and to intervene early to reduce the risk of fracture. A clinical diagnosis of osteoporosis can be made in a patient who has had a fragility fracture, independently of bone mineral density, although this is less desirable than diagnosing osteoporosis before the first fracture.

While one can argue that fracture risk assessment is of greater clinical importance than diagnostic classification (ie, normal, osteopenia, osteoporosis), a diagnosis of osteoporosis conveys a clear message to the patient and health care providers about the presence of a disease that requires evaluation and treatment. Also, in the United States, diagnostic classification is necessary to select a numerical code for insurance billing and sometimes to determine eligibility for insurance coverage of drug therapy.

Osteoporosis is underdiagnosed, even after fractures

Osteoporosis is underdiagnosed.1 Data from Medicare claims for 1999 to 2000 showed that only 30% of eligible women age 65 and older had a bone density test,8 despite recognition by many organizations that fracture risk is high and DXA is indicated in this population.7,9,10

An adult with any fracture,11 even one due to trauma,12 may have osteoporosis, may be at risk of future fractures, and should be considered for further evaluation. Vertebral fractures, the most prevalent type of osteoporotic fracture, are commonly underrecognized and underreported,13,14 thereby missing an opportunity to identify and treat a patient at high risk.

Clinical vertebral fractures are those that come to clinical attention because of symptoms and then are appropriately diagnosed, while morphometric vertebral fractures are those detected by an imaging study regardless of symptoms. Only about one-third of all vertebral fractures are clinically apparent.15

In 2005, Foley et al16 reported that only 10.2% of women age 67 and older with a fracture were tested for osteoporosis within the following 6 months. Patients discharged from the hospital after hip fractures are commonly not diagnosed with or treated for osteoporosis,17,18 although the risk of future fractures is very high.19 Inpatient consultation with a medical specialist has not consistently improved osteoporosis care, with some reports of no effect17 and others suggesting a modest benefit.20,21

Many factors are responsible for underdiagnosis, and no single specialty is to blame. Primary care physicians are often overburdened with clinical, administrative, and regulatory responsibilities that leave little time to consider a silent disease that increases the risk of an event that may occur far in the future. Acute fractures are often treated by an orthopedist or emergency department specialist who is not responsible for long-term care and prevention of future fractures. The primary care physician may not become aware of the fracture until long after it has occurred.

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