Osteoporosis: Identifying Risk to Reduce the Incidence of Bone Fracture
It is estimated that over 50 million older adults in the United States are affected by osteoporosis or low bone density. Over half of those 50 years or older are affected—10% with osteoporosis and over 40% with low bone mass.1 The increased risk of hip or vertebral fracture among this group represents a considerable burden to the health system.
Dr. Naim Maalouf, MD, Associate Professor of Medicine, University of Texas Southwestern Medical Center, discusses the importance of identifying those with osteoporosis or low bone density, and the interventions available to reduce the risk of fracture in those patients.
Identifying those at risk
“Osteoporosis is a silent condition,” notes Dr. Maalouf. “So until there is a fracture there may not be signs of its presence. That’s why screening, patient identification, and treatment before a fracture occurs is critical.”
Those at highest risk for osteoporosis and fracture are post-menopausal women, and older individuals. In terms of race, Caucasians followed by Asians are at highest risk. In addition to these major categories, patients with chronic kidney disease, and those on certain medications such as glucocorticoids are at particularly high risk, as well as smokers and those with high alcohol use.
“There are also a number of less common conditions that are associated with osteoporosis, which is why screening for these secondary causes is recommended,” says Dr. Maalouf.
There are approximately 100 or more conditions in this category. Early menopause, low testosterone in men, smoking and alcohol abuse are all secondary causes. Some of the other common factors are: endocrine causes, including primary hyperparathyroidism, over-active thyroid disease, and Cushing syndrome; rheumatic conditions, such as rheumatoid arthritis and ankylosing spondylitis; some hematological conditions, including multiple myeloma; some gastrointestinal disorders such as inflammatory bowel disease and celiac disease and infectious conditions like HIV, which increase the risk of osteoporosis and osteoporotic fractures.
Screening and Diagnosis
“For patients with major risk factors, a bone density scan should be performed,” says Dr. Maalouf. “In general, this is approved by Medicare for all women above the age of 65, and in women over 50 if they have additional risk factors for osteoporosis. Medicare does not currently reimburse for bone density screening for men, however there are several societies that recommend screening men at the age of 70 or earlier if they have risk factors or certain conditions, which may put them at risk.2-4
“The process to identify those who may be affected by secondary causes includes a detailed history and certain screening laboratory tests. Since it’s impossible to check for each individual disease, testing should start with some general tests, including a comprehensive metabolic profile, a complete blood count, a vitamin D and calcium levels and, in certain cases, urine testing for calcium and creatinine. In men, it’s important to rule out testosterone deficiency, which may be an underlying cause.
“Depending on the results of the history and screening tests, the physician may want to expand the work-up and order additional tests.”
Treatment of osteoporosis
The treatment of osteoporosis and allied conditions includes both lifestyle modifications and pharmacological intervention.
“Lifestyle measures apply to everybody with osteoporosis and those at risk for osteoporosis,” notes Dr. Maalouf. “Some important steps include reducing alcohol consumption to no more than 2 alcoholic drinks per day; smoking cessation; improve calcium intake to meet the recommended daily allowance either through diet or supplements; the use of vitamin D supplements as needed to optimize calcium absorption. Exercise and fall prevention are also important interventions.”
There are three major indications for prescribing FDA-approved medications for osteoporosis, explains Dr. Maalouf. “First, a history of an osteoporotic fracture, such as a low-trauma hip or a vertebral fracture. The second category comprises those who are shown to have osteoporosis by bone mineral density testing. The third category include those who have low bone density (osteopenia) but that do not meet criteria for osteoporosis, and are at high risk for fracture over the next ten years according to the Fracture Risk Assessment Tool (FRAX®).5
“The majority of approved medications for first-line therapy are bisphosphonates. Bisphosphonatesapproved for use in the U.S. include alendronate, risedronate, ibandronate and zoledronic acid. These antiresorptive agents primarily work to reduce bone loss and have been shown in clinical trials to reduce the risk of fracture in osteoporotic patients by 40-60% compared to placebo.5 This reduction in the risk of fracture is significant, however, some patients on bisphosphonates may still sustain fractures due to falls or other factors.
“For those who cannot tolerate these first-line drugs, or who may have other specific risks, second-line therapies may be appropriate.” Selective estrogen receptor modulators can be considered for younger postmenopausal women at greater risk for vertebral than hip fractures or as second-line therapy. Low-dose hormone therapy may be appropriate as prevention in women with menopausal symptoms at lower fracture risk. Denosumab is an injectable medication appropriate for women at high fracture risk or who have failed other osteoporosis therapies. It may also be considered in patients with renal insufficiency. Finally, anabolic therapies (bone forming agents) should be considered for high-risk patients.6
The choice of therapy is a shared decision between the treating provider and the patient and tailored to the patient’s specific condition. “It’s also important to note that certain medications should only be used for defined periods of time and continuous long-term use may have to be curtailed depending on the risks and response to the drug,” observes Dr. Maalouf.
Heightened awareness of the risk of osteoporosis among physicians and patients is critical to enable early intervention through lifestyle changes and/or medication. “The impact of hip and vertebral fractures on independence, mobility, and even overall mortality, is extremely large,” concludes Dr. Maalouf. “If we can prevent an osteoporotic fracture from occurring, then we could make a major difference in terms of quality of life and possibly mortality for the individual patient and the patient’s family.”
1. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the united states based on bone mineral density at the femoral neck or lumbar spine1 J Bone Miner Res.2014; 29:2520–2526.
2. Qaseem A, Snow V, Shekelle P, Hopkins R, Forciea A M, Owens DK. Screening for Osteoporosis in Men: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2008;148:680-684.
3. Cosman, F., de Beur, S.J., LeBoff, M.S. et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int.2015;26: 2045-2047.
5. Jansen JP, Bergman GJ, Huels J, Olson M. The efficacy of bisphosphonates in the prevention of vertebral, hip, and nonvertebral-nonhip fractures in osteoporosis: a network meta-analysis.Semin Arthritis Rheum. 2011;40:275-84.
6. Silverman S, Christiansen C. Individualizing osteoporosis therapy.Osteoporos Int.2012;23:797-809.
Associate Professor of Medicine
University of Texas Southwestern Medical Center