Physician's Weekly Article - Preventing Osteoporotic Fractures in Women

       The Agency for Healthcare Research and Quality has released a guide for clinicians that evaluates efficacy and safety of current available treatments for preventing fractures in postmenopausal women with osteoporosis.

      According to the Agency for Healthcare Research and Quality (AHRQ), approximately 1.5 million people in the United States experience a fracture related to osteoporosis each year. It is estimated that about 20% of those who experience hip fractures dies. In order to reduce the risk of fractures in women with postmenopausal osteoporosis, the AHRQ released a clinician’s guide that summarizes the effectiveness and safety of available treatments for preventing fractures. “Deciding on a treatment route for preventing osteoporotic fractures is a challenge due to the number of treatment options available,” says David H. Hickam, MD, MPH. “Instead of recommending a best course of action, the guide presents physicians with current evidence on available medications so that they can make well-informed decisions in an effort to optimize outcomes for patients.”

      The risk for fractures among postmenopausal women with osteoporosis can be estimated by using bone mineral density (BMD) testing, most notable the dual-energy x-ray absorptiometry (DXA).The lower the DXA reading, the higher the patient’s risk for fracture. “Women aged 60 and older are recommended to undergo a BMD test,” Dr. Hickam notes. “Other patients at increased risk for fractures are women who have previously had a fragility fracture—a fracture associated with minimal trauma.”

      Making Treatment Decisions

      A key component of the treatment selection process in postmenopausal women with osteoporosis is considering possible barriers to adherence, including modes of administration, dosing regimens, and cost (Table 1). Dr. Hickam explains that the dosage regimens of drugs that are designed to prevent osteoportic fractures are evolving rapidly. “Some bisphosphonates are available as injections,” he says. “These formulations offer potential advantages in that they have to be taken at fairly infrequent intervals, such as once a week or once a month, instead of daily.”

      Dr. Hickam says that physicians will often find that their patients usually have a preference when it comes to taking medicines orally or via injection. “A unique aspect of this clinical area is that there are choices for both oral and non-oral medication delivery. It’s important for physicians to discuss with their patients how they feel about the currently available alternatives.”

      Consider Risk of Adverse Events

      The AHRQ guide also encourages physicians to consider the risk of adverse events when determining the most appropriate treatment route. The guide recommends that physicians determine if patients have a history of medical conditions that constitute the side effects of the individual medications. For example, the use of bisphosphonates should be avoided in women with a history of serious gastrointestinal (GI) disease. Zoledronic acid should also be avoided in women who are at high risk for atrial fibrillation. The side effects of treatments to prevent osteoporotic fractures should also be taken into consideration. Potential side effects include GI problems, such as acid reflux, nausea, vomiting, heartburn, and ulcers, as well as atrial fibrillation, musculoskeletal pain, and osteonecrosis of the jaw.

      Furthermore, the ability of a drug to prevent hip fractures is an important concern for many physicians. Dr. Hickam says this is because hip fractures are considered to be the most serious type of fracture. “While evidence strongly supports the efficacy of certain drugs—including alendronate, rosedronate, zoledronic acid, and estrogen—to prevent fractures, data are still lacking among the majority of other available drug options.”

      Non-Pharmalogical Treatment & Precautions

      In addition to providing clarity on the efficacy and safety of treatments for preventing fractures among postmenopausal women with osteoporosis, the AHRQ guide provides suggestions on possible non-medical treatments to maintain bone health. Such therapies include integrating adequate calcium and vitamin D into diet (Table 2) as well as participation in an exercise regimen. “Smoking cigarettes and consuming alcohol have also been shown to increase the risk of fractures,” says Dr. Hickam, “so these factors should be addressed by clinicians managing these patients. In addition, physicians should make efforts to initiate interventions aimed at reducing risks for falling so that future fractures can be prevented. Clinicians should understand that muscle weakness and neurologic and joint problems can increase the risk of falls. These factors should be evaluated when considering treatment.”

      A significant amount of research is available on osteoporotic fracture prevention treatment, says Dr. Hickam, and suggests that further research may provide clinicians with more information about the available drugs for treatment. “Even though we have solid evidence-based data at this point, more research and investigations will further enhance physicians’ ability to guide their patients with effective and safe treatments. We can also help patients make treatment decisions that are more geared towards their individual preferences.”

      David H. Hickam, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.