Now, let's talk about osteoporosis.
And to me, this is
often a forgotten diagnosis,
particularly among our older patients.
But I bet that if you had a
grandmother or your mother
who suffered a fracture of
her spine or of her hip,
you’re not going to forget about it.
It is a serious diagnosis that carries
potentially devastating consequences for patients
and, therefore, it's worth
a minute to talk about it.
So, let's go.
We’re going to be discussing the
risk of fracture overall,
how to screen for it.
And I thought we’d start with a case.
This is a 66-year-old white woman
presenting for a wellness visit.
She has no past medical
history and no complaints.
That's a rare event.
She has no family history of
osteoporosis or fracture in particular.
Now, what should you offer her to
screen for her risk of fracture.
A, nothing, she has no risk factors;
or B, nothing, only African-American women
should be screened for osteoporosis;
C, screening with an
ultrasound of the calcaneus;
or D, screening with
DEXA of the hip and spine.
DEXA is dual absorption
The answer is D, DEXA.
So, DEXA scanning is the preferred
method for screening for osteoporosis.
She is over 65 and, therefore, meets
screening recommendations for screening –
for a screening exam.
The reason we think about
is that osteoporosis is very common,
affects more than 10 million Americans.
Overall, here's a graph that
shows the lifetime risk
of osteoporotic fracture
among white adults in particular
and we’ll talk about some of the racial
differences associated with osteoporosis.
You can see it’s much higher
for women among men.
That's why women are recommended
for screening, but men are not.
So, what are some
of the risk factors for osteoporosis?
Obviously, age. As we get older, our
bones become higher risk for fracture.
White or Asian race,
so those are the two racial
groups that are associated with
greater rates of
osteoporosis and fracture.
History of smoking,
family history of osteoporosis or fracture,
having a low body weight –
not a high bodyweight, but a low one –
and the biggest risk factor for an osteoporotic fracture
in particular is a previous osteoporotic fracture.
So, it's amazing to me that patients
come in and they already have a history of
compression fracture of the spine
or a fracture of the hip and/or
some other fragility-based fracture,
and yet they haven't been tested with
a DEXA nor are they on treatment.
Really, once you have an
it's a good idea to just initiate
and then do a DEXA scan as –
just to get a baseline
level of where the patient is.
But that is a tremendous risk
factor for another fracture,
is a previous fracture.
So, as I mentioned, the Dual Energy
X-Ray Absorptiometry study is preferred
and that starts at age 65 for
average risk patients.
For higher risk patients,
those who have a family history of
osteoporosis and fracture,
those have been on
corticosteroids for a long time,
there are some tools that can help to judge
when the patient should be screened and
if they deserve early screening for fracture risk.
Men, there's really not a clear
benefit to screening for men,
even those at higher risk.
So, therefore, there is no
strong recommendation to screen
broadly for osteoporosis among men.
And then, it is important for
clinical practice as well as your exam,
osteoporosis defined by that T score of at least
2.5 standard deviations below the mean.
The T score is the
comparison to the period in life
in the early 20s when you have
your greatest bone mass.
So, what did her DEXA test show?
She has a T score minus of 2.7.
So, now, which of the following routine laboratory tests
is indicated for this patient based on that DEXA score alone?
Is it HIV, TSH,
parathyroid hormone (or PTH),
or a complete blood count (CBC).
This patient, because her score is minus 2.7,
it's less than minus 2.5,
therefore, she fits the
criteria for osteoporosis.
All patients with osteoporosis
should be checked with a TSH
and they should also get a
calcium level and routine electrolytes.
Now, what's the best treatment option for this patient?
Yet another question.
How about calcium only,
calcium with vitamin D,
a bisphosphonate or calcitonin?
If you really want to
prevent fracture in this patient,
which is the ultimate goal,
we’re not looking to
necessarily increase bone density.
We want to maintain bone density,
but that's not even –
that's not an outcome the patient can feel, right?
That's something that we can measure.
But what we really want to prevent is fracture.
That's an important patient-oriented outcome.
And bisphosphonates have the
strongest track record for preventing fracture.
And they’re more effective overall for
preventing spinal versus hip fracture.
Number needed to treat is fairly low at 25,
but it can range up to 95 for
some studies looking at hip fracture.
But, again, preventing a spine
or hip fracture can be absolutely critical.
It can prevent the patient from
suffering complications due to immobility,
being placed in a nursing home.
So, there’s a lot of benefits
to preventing these fractures that
go beyond just the fracture itself.
However, current recommendations state that
after about five years of treatment among –
in a low risk woman,
it may be okay to consider
stopping treatment with bisphosphonates.
Second line agents for patients
who can't take or can't tolerate bisphosphonates
say they have a
history of severe esophagitis.
I have a patient in that situation.
And therefore, bisphosphonates
aren’t a great option for her
because of their associated risk of
Raloxifene can be a
good second line agent.
It's a selective estrogen receptor modulator.
Side effects can include vasomotor symptoms.
So, particularly for patients with
more severe menopausal symptoms,
it’s not a great option.
And there is some small increased
risk of venous thromboembolism.
It may also promote a very small increase
in the risk of breast cancer as well.
Whereas other drugs,
newer drugs for the application
against osteoporosis are really only used for
severe cases that
don't respond to normal therapy,
that's teriparatide or denosumab and
those are given in an endocrinology office.
Now, calcium and vitamin D do have a role.
And, of course,
patients with osteoporosis
should continue on calcium and vitamin D.
But using them alone among patients
with osteoporosis is insufficient
in terms of preventing fracture,
and so they need to be augmented
with one of these other agents.
Again, bisphosphonates preferable.
So, that's really what I wanted
to discuss with bisphosphonates.
Who should be screened,
some of the risk factors,
and then particularly
the treatment is really important.
So, when you identify it,
even if it's just a patient who
has a previous osteoporotic fracture,
initiate treatment with a
bisphosphonate with good warnings about
taking in the morning before eating a meal
and making sure that they’re upright to
prevent those esophageal complications.
They should do great and
prevent fracture down the road.