Physician's Weekly Article - Preventing & Treating Osteoporosis: A Focused Update

       New guidelines on osteoporosis provide evidence-based recommendations for all postmenopausal women and men over the age of 50 and introduce a new way to assess fracture risk.

      The National Osteoporosis Foundation (NOF) estimates that more than 10 million Americans have osteoporosis and 33.6 million have osteopenia. Fractures caused by osteoporosis or osteopenia account for more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions each year. In 2005, healthcare costs for osteoporotic fractures were estimated at $17 billion.

      Osteoporosis is a disease that can be prevented, diagnosed, and treated before fractures occur. Even after a first fracture, treatments that decrease the risk of further fractures are available. However, since the NOF published its first clinician’s guide to osteoporosis in 1999, it has become clear that many patients are not receiving information about prevention and undergoing appropriate testing. Ethel S. Siris, MD, says that after diagnosis, many patients are not being treated. “We have the knowledge base to improve the situation,” she says, “but there are huge gaps between what we know we should be doing and what we’re actually doing to improve bone health.”

      Recommendations Updated

      The NOF’s Clinician’s Guide for the Prevention and Treatment of Osteoporosis, released in February 2008, provides evidence-based recommendations, with a focus on fracture risk assessment. “The goal of the guide is to help physicians better understand levels of risk,” says Dr. Siris. “We want to be certain that patients at high-risk for fracture receive appropriate treatments to lower risk and encourage low-risk patients who do not require prescription medication to come back to their clinicians periodically for reassessment.”

      The clinician’s guide introduces a new approach to assessing fracture risk in previously untreated patients. The assessment is based upon the recently released World Health Organization algorithm on absolute fracture risk called FRAX. The clinician’s guide also provides recommendations for testing and treating patients besides those who are Caucasian postmenopausal women, including African-American, Asian, Latina, and other postmenopausal women and men aged 50 and older. “Over the years, we’ve learned much about the impact of osteoporosis on other ethnic groups and men, as well as Caucasian women,” Dr. Siris says. “We now have research data to provide guidance on managing osteoporosis in all women and men.”

      The FRAX Algorithm

      The FRAX algorithm integrates clinical risk factors with bone mineral density (BMD) to determine the 10-year probability of both hip fracture and “major osteoporotic fracture” (eg, vertebral, hip, distal forearm, and proximal humerus fractures). The NOF has adapted FRAX for U.S. populations by utilizing both fracture outcome and mortality data from American women and men (Table 1) and has carried out cost-effectiveness analyses to provide treatment intervention cut-points. Risk thresholds for pharmacologic treatment are based on whether it is cost effective to prescribe an osteoporosis medication to prevent future fractures.

      FRAX is especially valuable in assessing patients with osteopenia, according to Dr. Siris. “Although osteopenia patients account for the majority of fractures, they represent a ‘gray zone’ because there’s uncertainty about how to evaluate and treat them,” she says. “If the FRAX calculation is performed in patients with osteopenia, the answers may surprise clinicians. Someone who was viewed as being at high risk may not truly be at high risk, while others considered to be at low risk may actually be at high risk. The goal is to make sure high-risk patients are treated and low-risk patients receive prevention education.”

      Physicians can obtain absolute fracture risk in less than 2 minutes, according to Dr. Siris, by entering patients’ BMD hip T-score and other risk factors in a simple web-based version of the FRAX algorithm (with different versions for Caucasians, Asians, African Americans, and Hispanics). Although the software is still being reviewed by the FDA, when approved, it can be incorporated into the computers of about half of the currently available central dual-energy x-ray absorptiometry machines.

      Evaluation & Risk Assessment

      The updated clinician’s guide calls for physicians to evaluate all postmenopausal women and men aged 50 and older for osteoporosis risk to determine whether they need BMD testing. This testing should be performed on all women aged 65 and older and all men aged 70 and older, as well as younger people under specific circumstances (Table 2). The FRAX algorithm should be used in all previously untreated patients who have BMD testing. In addition, it is important for physicians to counsel all postmenopausal women and men aged 50 and older on their risk of osteoporosis and related fractures. They should be advised about prevention measures, such as adequate intake of calcium (1,200 mg daily) and vitamin D (800 IU to 1,000 IU of vitamin D3 daily); regular weight-bearing and muscle-strengthening exercise; fall prevention; avoiding tobacco use and excessive alcohol intake; and treatment of other risk factors, such as impaired vision.

      Ethel S. Siris, MD, has indicated to Physician’s Weekly that she has served as a consultant for Novartis, Procter & Gamble, Sanofi-Aventis, Amgen, and Eli Lilly. She is also on the speaker’s bureau for Procter & Gamble, Sanofi-Aventis, Eli Lilly, and Novartis.