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Osteoporosis Management in Women Who Have Had a Fracture

Date: 12/20/18

Osteoporosis is a “silent” disease until fractures occur. Bones become porous and fragile from loss of tissue or bone mineral density (BMD). BMD peaks early in adulthood and declines with age, leading to osteoporosis.

Of the 10 million people in the U.S. affected by osteoporosis, 80 percent are women. Another 44 million people have low BMD. Nearly half of all women in the U.S. will experience an osteoporotic fracture during their lifetime.

Individuals with osteoporosis are significantly more likely to experience low-trauma bone fractures. Identifying patient risk factors and utilizing BMD screenings are the most effective methods of primary prevention of osteoporotic fractures. Of postmenopausal women with one or more risk factors for developing osteoporosis, 18 percent actually undergo BMD screenings. BMD is measured as a T-score value. A T-score of -2.5 or lower indicates presence of osteoporosis.

Some risk factors may be modified and reduced.

Correcting modifiable risk factors can slow down the degeneration of bones, but adherence is difficult for most patients and usually not enough without pharmacotherapy.

Non-modifiable risk factors important for assessment include:

  • Advanced age
  • Gender
  • Cacasian or Asian race
  • Low BMI, of small stature
  • Early onset menopause, fewer reproductive years
  • Variety of medical conditions

Risk factors that can be modified are:

  • Alcohol use
  • Tobacco use
  • Frequent falls
  • Inadequate physical activity
  • Vitamin D insufficiency
  • Excessive thinness
  • High salt intake
  • Low calcium intake
  • Excess vitamin A
  • Immobilization

Certain medications may also put patients at risk. To some extent, these medications may be somewhat modified. These include:

  • Long-term glucocorticoid use
  • Cyclosporine, Tacrolimus
  • PPIs, Aluminum
  • Progesterone-only contraceptives
  • Aromatase inhibitors, MTX, Tamoxifen (premenopausal use)
  • Gonadotropin RH, Excess thyroid hormone
  • TPN, Heparin
  • Anticonvulsants, Barbituates
  • SSRIs, Lithium

Recommendations to reduce risk for osteoporosis include:

  • Calcium and vitamin D
  • Weight-bearing and muscle-strengthening exercises
  • Smoking cessation
  • Limiting alcohol intake (≤ 3 alcoholic beverages/day)
  • Fall prevention

Following approved treatment recommendations is key.

Teach and encourage patients to read nutrition labels on dietary supplements. Multivitamins contain 20-30 percent daily calcium requirements. Take calcium in divided doses (max 500mg absorbed at a time). Calcium can interact with medications, therefore has to be monitored.

Diagnostic criteria vary between organizations, such as those defined by American Association of Clinical Endocrinologists and World Health Organization. All recommendations suggest labs to identify and address possible secondary causes for osteoporosis, including serum vitamin D levels, calcium, creatinine and Thyroid Stimulating Hormone.

Goals of therapy include to prevent fractures by improving bone strength, reduce the risk of falling and injury, relieve symptoms of fractures and skeletal deformity and maximize physical function.

Osteoporosis is commonly treated with medications that help restore the mineral content of bones by facilitating calcium uptake. Some of these medications are also used to prevent progression of osteoporosis in patients with low BMD.

The National Osteoporosis Foundation (NOF) recommends pharmacologic treatment for postmenopausal women who meet ONE the following criteria:

  1. A hip or spine fracture (either clinical spine fracture or radiographic fracture)
  2. A T-score of -2.5 or below at the spine, femoral neck, or total hip
  3. A T-score between -1.0 and -2.5 and either one of: 10-year risk of 3% or more for hip fracture or 10-year risk of 20% or more for “major” osteoporosis-related fracture.

First-line therapy are bisphosphonates which include Alendronate (Fosamax®), Ibandronate (Boniva®), Risedronate (Actonel®), and Zoledronic Acid (Reclast®). Alternative therapies include Selective Estrogen Receptor Modulator: Raloxifene (Evista®), Parathyroid hormone: Teriparatide (Forteo®), RANKL/RANKL Inhibitor: Denosumab (Prolia®). Calcitonin is considered last line of therapy.

Oral bisphosphonates: must follow specific directions to maintain efficacy and prevent adverse drug reactions.  Forteo® & Prolia® are specialty drugs, typically filled by mail-order pharmacies in which patients not likely to receive face-to-face consultation with a pharmacist. Counsel patients on proper storage and use, then ask them to demonstrate it for you to make sure they understand how to use medication and what to expect.

1.     Camacho, Pauline M., et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis – 2016. AACE/ACE Postmenopausal Osteoporosis CPG, Endocr Pract. 2016;22(Suppl 4).

2.     Hauk, Lisa. Treatment of Low BMD and Osteoporosis to Prevent Fractures: Updated Guideline from the ACP. American Family Physician. March 1, 2018; 97 (5): 352-353.

3.     Jeremiah, Michael P.; Unwini, Brian K.; Greenawald, Mark H. Diagnosis and Management of Osteoporosis.  Am Fam Physician. 2015;92(4):261-268.

4.     Nayak, S. and Greenspan, S. L. (2018), How Can We Improve Osteoporosis Care? A Systematic Review and Meta‐Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis. J Bone Miner Res. . doi:10.1002/jbmr.3437.