Shifts in Diagnosing and Treating Osteoporosis

Keaton M Nasser, Andrew D Calderon, Stuart L Silverman
US Musculoskeletal Review, 2011;6(1):20-4
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Abstract

Timely diagnosis and effective treatment of osteoporosis is important in the prevention of related fractures. It is vital for physicians to not only properly identify patients who are at high risk and who need treatment, but also to understand their patient’s preferences, so that they can prescribe an effective treatment. The traditional bone mineral density diagnosis leaves a large population of patients who are at risk for fracture untreated and has led to an increased reliance on clinical risk factors. Objective risk factor assessment tools have been developed to help identify patients who are at risk for fracture. As an asymptomatic disease, poor adherence with treatments has proven to be a major factor when treating osteoporosis. To improve adherence and to better understand patient preferences, studies have been performed using various techniques to elucidate what factors are most important to patients. Conjoint analysis can be used to help physicians understand their patient’s preferences and, ultimately, increase adherence and successful treatment of osteoporosis.
Keywords
Osteoporosis, Fracture Risk Assessment Tool (FRAX), fracture risk
Disclosure Stuart Silverman, MD, FACP, FACR, has received grants from Eli Lilly & Co and the Alliance for Better Bone Health. He has received honoraria from Eli Lilly & Co, Roche Pharmaceuticals, and Pfizer. He has also consulted for Warner Chilcott, Roche Pharmaceuticals, Roche Diagnostics, Novartis, Pfizer, and Eli Lilly & Co.
Received: April 15, 2011 Accepted May 06, 2011
Correspondence: Keaton M Nasser, BS, Osteoporosis Medical Center, 8641 Wilshire Blvd, Ste 301, Beverly Hills, CA 90211. E: keatonn@omcresearch.org

With a rapidly increasing older population, osteoporosis is a major public health concern because of the increased rates of fracture. Timely diagnosis and effective treatment is important in the prevention of osteoporotic-related fractures because of their association with high morbidity and mortality, impaired quality of life, physical decline, and high cost. It is vital for physicians to not only properly identify patients who are at high risk and need treatment, but also to understand their patient’s preferences, so that they are able to prescribe an effective treatment.

Diagnosing Osteoporosis
Osteoporosis has been historically diagnosed using bone mineral density (BMD) assessments by dual X-ray absorptiometry (DXA). In 1994, the WHO defined osteoporosis as having a T-score of 2.5 standard deviations below the peak BMD and low bone mass, formerly osteopenia, between -1 and -2.5.1 This has been the traditional benchmark for selecting patients for treatment. However, with reducing fracture incidence as the primary goal of osteoporosis treatment, deciding who is at risk based on the BMD definition of osteoporosis is specific but not sensitive.9 The most pressing limitation currently is a lack of awareness and identification. The National Osteoporosis Foundation (NOF), Council of the Osteoporosis Society of Canada (COSC), and National Osteoporosis Guideline Group (NOGG) guidelines all have recommendations for DXA screening for patients over 65 years of age.2–4 In the US, only 31% of Caucasian women and less than 5% of men over 65 years of age have undergone DXA testing.5 Even in developed countries, it is economically unfeasible to use BMD screening to test large populations. In addition, identification of individuals at risk using the traditional BMD definition is specific, but not sensitive—it does not accurately capture the patient population at risk for fracture. Based on data from the Study of Osteoporotic Fractures (SOF), 54% of new hip fractures occurred in women who did not have osteoporosis as determined by their BMD.6 Based on data from the National Osteoporosis Risk Assessment (NORA), 82% of post-menopausal women with fractures had peripheral T scores better than -2.5.7

The limitations of using BMD alone have led to an increased reliance on clinical risk factors for determining fracture risk. The NOF revised its guidelines to include risk. The NOF suggests that any individual with either a hip or vertebral fracture, a T-score below -2.5, a low bone mass, a 10-year probability of a hip fracture ≥3%, or a 10-year probability of a major osteoporosis-related fracture ≥20% should be treated for osteoporosis.2 Clinical risk factors include age, body mass index (BMI), history of fragility fractures and family history of fracture. Although previous guidelines have accounted for risk factors, they did not account for multiple risk factors of different weighting (see the earlier NOF guidelines). However, because risk factors are additive, and not independent of one another,3 research groups have developed objective assessment tools to identify patients who are at high risk for fracture. Using assessment tools in combination with BMD screening can close the gap between those at risk for fracture and those being treated, ultimately reducing the incidents of fracture. Using the WHO’s Fracture Risk Assessment Tool (FRAX)8 and the new NOF guidelines,2 only 26% ofUS Caucasian women with a high risk for fracture receive treatment.7 These data suggest that diagnosis by BMD alone leaves a large population untreated and at risk for fracture.

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Shifts in Diagnosing and Treating Osteoporosis

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