Fracture prevention in COPD patients; a clinical 5-step approach

Abstract

Although osteoporosis and its related fractures are common in patients with COPD, patients at high risk of fracture are poorly identified, and consequently, undertreated. Since there are no fracture prevention guidelines available that focus on COPD patients, we developed a clinical approach to improve the identification and treatment of COPD patients at high risk of fracture. We organised a round-table discussion with 8 clinical experts in the field of COPD and fracture prevention in the Netherlands in December 2013. The clinical experts presented a review of the literature on COPD, osteoporosis and fracture prevention. Based on the Dutch fracture prevention guideline, they developed a 5-step clinical approach for fracture prevention in COPD. Thereby, they took into account both classical risk factors for fracture (low body mass index, older age, personal and family history of fracture, immobility, smoking, alcohol intake, use of glucocorticoids and increased fall risk) and COPD-specific risk factors for fracture (severe airflow obstruction, pulmonary exacerbations and oxygen therapy). Severe COPD (defined as postbronchodilator FEV1 < 50% predicted) was added as COPD-specific risk factor to the list of classical risk factors for fracture. The 5-step clinical approach starts with case finding using clinical risk factors, followed by risk evaluation (dual energy X-ray absorptiometry and imaging of the spine), differential diagnosis, treatment and follow-up. This systematic clinical approach, which is evidence-based and easy-to-use in daily practice by pulmonologists, should contribute to optimise fracture prevention in COPD patients at high risk of fracture.

Figure 1

A multistep evaluation and treatment plan for fracture prevention in COPD. DXA = dual energy X-ray absorptiometry of hip and lumbar spine; VFA = vertebral fracture assessment with DXA.

Figure 2

Evaluation of fracture risk in COPD patients. DXA = dual energy X-ray absorptiometry of hip and lumbar spine, FRAX = fracture risk assessment tool, VFA = vertebral fracture assessment with DXA, X-spine = X-ray of the spine. This figure is based on the Dutch guideline on osteoporosis and fracture prevention [16].

Figure 3

Flowchart for follow-up. This figure is based on the Dutch guideline on osteoporosis and fracture prevention [16].

Figure 4

Re-evaluation after 5 years of treatment with bisphosphonate or 2 years of treatment with teriparatide. This figure is based on the Dutch guideline on osteoporosis and fracture prevention [16].