The clinician's guide to prevention and treatment of osteoporosis

Abstract

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Keywords: Bisphosphonate holiday; FRAX®; Fracture risk stratification; Fractures; Novel antifracture therapies (romosozumab, denosumab, abaloparatide); Osteoporosis; Primary care management of osteoporosis; Vertebral imaging.

Fig. 1

Hip fracture incidence in postmenopausal women across ethic/racial populations in WHI data (from Nelson DA et al. Osteoporos Int. 2011) [19]

Fig. 2

Incidence of hip fractures (age-adjusted) between 2002 and 2015 according to Medicare claims. Note the decade-long decline in hip fractures and plateau between the years 2013 to 2015. (Lewiecki EM, et al. [2018] Osteoporos Int. Reprinted with added arrow by permission of author.) [31]

Fig. 3

Micrographs of normal (left) and osteoporotic (right) bone. As trabecular mineral is depleted, individual bony plates and connecting branches are lost, leaving less resilient, weaker bone that is more likely to fail under normally tolerated mechanical loads. Dempster, DW et al. (1986) J Bone Miner Res 1:15-27. Reprinted with permission [50]

Fig. 4

Hip BMD showing low bone mass and a history of a fracture. The FRAX® score indicates an elevated absolute risk of major osteoporotic and hip fracture

Fig. 5

This contrast between percentage of people in general population who use wheelchairs (0.859 in 100) and the percentage who use wheelchairs following hip fracture (25 in 100). Sources: 2010 US Census Data [140, 141]

Fig. 6

Management of long-term bisphosphonate (BP) treatment in postmenopausal women. Note: This flowchart illustrates ASBMR task force recommendations for management of patients taking bisphosphonates. All other osteoporosis drugs lose effect rapidly when discontinued and must be promptly followed by alternative antifracture therapies. Adler RA, et al. (2016), J Bone Miner Res [15]

Fig. 7

Daily activities and household chores can be modified to minimize risk for vertebral fractures. (NOF [2019] Boning Up on Osteoporosis) [354]

Fig. 8

For people with osteoporosis, the harm or benefit conferred by exercise depends on the specific movement involved. Activities that require spinal flexion (forward bending) increase risk of vertebral fracture, while activities that involve spinal extension decrease risk [355]. (Source: Sinaki M, Mikkelsen BA [1984] Arch Phys Med Rehabi)