Osteoporosis IMP: Act
(Identify – Manage – Prevent: Act)
What is IMP:Act?
A WSOA initiative to raise awareness of the need for more effective management of the growing public health care problem of osteoporosis through collaboration of likeminded medical specialties to improve the health of the public and save precious health care resources. by application of simplified expanded screening efforts and more timely interventions as suggested by the AOA ‘Own the Bone’ program.
Some Osteoporosis Facts:
Definition:
Osteoporosis is the loss of bone mineral density decreased bone quality that results in reduced strength and increased risk of fracture. This can be caused when the body loses too much bone, makes too little bone or both (BHOF).
Traditionally Osteoporosis was determined based on bone mineral density from DEXA scanning using world health organization WHO criteria. These are reported as T scores which are the standard deviations from a reference standard in the United States being young Caucasian adult females.
| WHO Classification based on lowest t-score of femoral neck, total hip and lumbar spine |
| T-score |
Classification |
|
| >-1.0 |
Normal bone |
|
| -1.0 to -2.4 |
Osteopenia |
|
| < -2.5 |
Osteoporosis |
|
Recently osteoporosis is diagnosed to include bone mineral density fracture history and fracture risk. (AACE, BHOF). Patient meeting any of these criteria are considered candidates for pharmacologic and physical therapy.
| Clincal Diagnosis of osteoporosis |
|
| T-score < -2.5 |
| Fragility fracture of hip or spine since age 50 |
| Osteopenia and a high fracture risk using Fracture Risk Assessment Tool FRAX. |
| A 10-year hip fracture risk of > 3% or major osteoporotic fracture risk of 20% |
|
How often does it happen? (1,2,3,4)
- 1/3 women and 1/5 men after age 50 will have at least one osteoporotic fracture
- 9 million facture s/ year worldwide (51% in Europe and US)
- Hip, forearm with wrist, vertebrae most common
- By 2050 compared to 1990 hip fractures will increase 240% in women and 310% in men
How bad is it? (2)
- Women lose 2% of bone mass per year after menopause.
- Women older than 45 years spend more days in hospital from osteoporosis than breast cancer, diabetes, myocardial infarctions together.
- 86% of women have a second osteoporotic fracture if not treated for osteoporosis
- 25% of hip fracturs happen in men, they suffer from a 20% higher mortality than women
- Lifetime risk of osteoporotic fractures is 27 % for men (more than twice the risk of prostate cancer (11%)
- There is loss of independence after osteoporotic related fractures which is of greatest concern to patients
Risk factors
Genetic problems:
- Female
- White and Asian race
- Personal or family fracture history
- Older patients
Intake problems:
- Low calcium intake
- Low Vit D diet
- Alcoholism
- Nicotine use
- Limited exercise
- Bone toxic medication e.g., anticonvulsant and daily corticosteroids
Medical conditions:
- Diabetes
- Low estrogen
- Low testosterone
- Intestinal malabsorption syndromes
- Multiple myeloma/ monoclonal gammopathy of unknown significance (MGUS)
- Renal failure
- Rheumatoid arthritis
- Inflammatory bowel disease
- History of falling
Countermeasures (2)
- Increase awareness / education
- Minimize modifiable risk factors
- Sufficient exercise (aerobic, strength, posture, balance)
- Improve nutrition
- Calcium intake
- Daily Vitamin D
- Rehabilitation efforts – Physical Medicine, Occupational Therapy, education, practitioner surveillance
Diagnostics (3,4)
- Regular radiographs (XRays) – recognize typical fragility fractures and report
- DXA: (Dual photon absorptiometry)
- Derivatives of DXA can increase sensitivity including trabecular bone score and vertebral fracture assessment
- Opportunistic CT scan screening: Calculate CT attenuation using Hounsfield (HU) units (Spine, Hips, wrists)
- Dedicated other CT techniques (Synchronous, asynchronous quantitative CT, phantomless qCT).
Medications: (2,5,6)
Antiresorptive agents – inhibits osteoclasts
- Bisphophonates
- Alendronate (Fosamax, Binosto)
- Risedronate (Actonel)
- Ibandronate (Boniva)
- Zoledronic acid (Reclast) (IV typically given yearly)
- Denosumab (Prolia) – Antibody that binds RANK ligand thus inhibiting osteoclastic differentiation. Given as twice-yearly injections
- Raloxifene (Evista) selective estrogen inhibitor
- Calcitonin (Miacalcin) – Hormonal agent that inhibits osteoclastic function
Anabolic agents (bone forming agents)
- Teriparatide (Forteo) PTH analog given by daily injection
- Abaloparatide (Tymlos) PTH analog given by daily injection
- Romosozumab antisclerostin antibody that has both anabolic and antiresorptive properties
Transition of medication 6
All patients being treated for osteoporosis should have a transition plan for how long the medication is continued and what if any medication’s will be needed.
For the spots and eats a trial of 3 to 5 years with a reassessment of risk and consideration of drug holiday at that time.
Denosumab should never be discontinued without transition to bisphosphonate or anabolic agent secondary to rapid long bone loss and potential for multiple spinal fractures.
The anabolic medications should be transition to bisphosphonates or denosumab to lock in any gains in bone mineral density and reduced fracture risk.
Rehabilitation efforts5
All patients with osteoporosis should receive rehabilitation efforts aimed at reducing falls and spontaneous fractures by improving body posture, balance and receiving formal training in fall prevention.
Continuity of Care5,6
Long term joint efforts by Primary Care Physicians, Radiologists, Emergency Room practitioners, interested Surgeons and the Interventionalist community as well as public health care minded politicians are needed to bend the rising curve of osteoporosis and its deleterious effects on patient and health care costs.
References:
1. Ballane G, Cauley JA, Luckey MM, El-Hajj Fuleihan G (2017) Worldwide prevalence and incidence of osteoporotic vertebral fractures. Osteoporos Int 28:1531–1542
2. Matskin EG, De Maio M, Charles JF, Franklin CC: Diagnosis and treatment of osteoporosis: What orthopaedic surgeons need to know. J Am Acad Orthop Surg. 2019. Vol 27, No 20 e902-e912
- Anderson PA, Polly D, Binkley NC, Pickhardt PJ: Clinical use of opportunistic computed tomography screening for osteoporosis. J Bone Joint Surg Am 2018; 100:2073-81
4. Blecher R, Ylmaz E, Ishak B, vGlinski A, Moisi M, Oskouian RJ, Detorri J, Kramer M, Drexler M, Chapman JR: Uptrend of cervical and sacral fractures underlie increase in spinal fractures in the elderly, 2003–2017: analysis of a state-wide population database. Europ Spine J (2020); 29:2543-2549
5. LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022 Apr 28. doi: 10.1007/s00198-021-05900-y. Epub ahead of print. PMID: 35478046.
- Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. American Association of Clinical Endocrinologists/American College of Endocrinology. Clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis- 2020 update <i>EXECUTIVE SUMMARY</i>. Endocr Pract. 2020 May;26(5):564-570. doi: 10.4158/GL-2020-0524. PMID: 32427525.
