Managing osteoporosis: Challenges and strategies
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.
Educate patients to improve compliance
Many patients who are prescribed medication do not start taking it, take it incorrectly, or stop taking it before obtaining benefit.
Some patients may not understand the goal of therapy (reduction of fracture risk) or the serious consequences of fractures. The lay press and medical journals contain much information on potential adverse effects of drug therapy (eg, osteonecrosis of the jaw, atrial fibrillation, mid-shaft femur fractures, esophageal cancer with bisphosphonates), often presented without consideration of the benefit-risk ratio. Patients may fear real or perceived adverse effects, and physicians may not be sufficiently knowledgeable to allay those fears.
For drugs that are complex to administer, such as oral bisphosphonates, patients may not fully understand the requirements or their rationale and importance.
For these reasons, a patient who is prescribed a drug must also be educated about the importance of filling the prescription, taking it regularly and correctly (particularly important for oral bisphosphonates), and taking it long enough to benefit.
Keep in touch with the patient
The causes of poor compliance and persistence are many, and effective interventions to help are few.50 One approach that has been shown to be helpful is regular contact with a health care provider.51
Patients often stop treatment when they develop an adverse effect (real or perceived), or when a news release of a new medical report raises the fear of an adverse effect. Without contact with a health care provider, these issues cannot be recognized and addressed.
Monitor for effectiveness
Monitoring for effectiveness of therapy, usually with DXA 1 to 2 years after starting therapy, provides useful clinical information.
Stability or an increase in bone mineral density is considered a good response that is associated with a reduction in fracture risk.7 A significant loss of bone mineral density is cause for concern and consideration of evaluation for secondary causes.52,53
Allowable intervals for insurance coverage of DXA may vary according to Medicare jurisdiction and health plan.
SHOULD BISPHOSPHONATES BE STOPPED AFTER LONG-TERM USE?
The concept of a “drug holiday” has arisen because bisphosphonates have a prolonged but waning antiresorptive effect with discontinuation after long-term use. A drug holiday, for a period of 1 year or perhaps longer, may be considered for patients on alendronate who are no longer or never were at high risk of fracture. On the other hand, given the evidence of increased risk of clinical vertebral fracture54 and hip fracture55 after bisphosphonates are discontinued, a drug holiday is probably not a reasonable choice in patients at high risk of fracture.
For bisphosphonates with very long dosing intervals, such as zoledronic acid given intravenously every 12 months, there may be opportunities for extending the dosing interval, but the lack of data means that no recommendations can be made at this time.
WHEN TO REFER
Most patients with osteoporosis can be effectively managed by the primary care provider. Referral to an osteoporosis specialist should be considered when the evaluation or treatment is beyond the comfort zone or level of expertise of the provider. Examples of situations in which referral may be appropriate are young patients with fragility fractures, patients with normal bone mineral density and fragility fractures, unusual laboratory findings on the evaluation for secondary osteoporosis, poor response to therapy (declining bone mineral density, failure of bone turnover markers to change as expected, fractures), and inability to tolerate therapy.
