Postmenopausal osteoporosis: Another approach to management

,

Applied Evidence

Postmenopausal osteoporosis: Another approach to management

J Fam Pract. 2010 June;59(6):E1-E7

By

Raymond Cole, DO

The effectiveness of oral bisphosphonates is compromised by poor compliance. IV bisphosphonates provide another option.

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References

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PRACTICE RECOMMENDATIONS

Using the World Health Organization’s online Fracture Risk Assessment Tool (FRAX) may help you decide when to initiate treatment for patients with osteopenia. C

Consider using intravenous bisphosphonates as first-line therapy for women with postmenopausal osteoporosis. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

To prevent bone loss and fractures in postmenopausal osteoporosis, the best choice of medication is one a patient will actually take. Bisphosphonates are the standard of care for maintaining or increasing bone mass and reducing excessive bone turnover,¹ and oral bisphosphonates have proven to be safe and effective in reducing osteoporotic fractures. However, numerous studies have shown that the effectiveness of oral bisphosphonates is compromised by poor patient compliance in taking the medication as directed and by poor persistence in continuing the medication over the long term.

Intravenous (IV) bisphosphonates are another option: They bypass the GI tract and thereby avoid the difficult requirements of oral dosing that many patients end up disregarding. And because IV administration occurs under medical supervision, it ensures persistence throughout the entire dosing interval. IV ibandronate 3 mg is administered every 3 months, and IV zoledronic acid 5 mg is administered once a year.

Osteoporosis and osteoporotic fractures are markedly underdiagnosed

Delmas and colleagues evaluated the underdetection of vertebral fractures in an international, multicenter prospective study of 2451 women 65 to 80 years of age who had not received a diagnosis of osteoporosis.² Expert review of radiographic reports identified at least 1 mild vertebral fracture in 32% of the study population, but one-third of these cases had not been identified before the review.

Determine bone mineral density. Detection of osteoporosis depends in part on measuring bone mineral density (BMD) of the hip and spine by dual-energy x-ray absorptiometry scan. BMD correlates with bone strength and helps predict fracture risk. The World Health Organization has established definitions for bone integrity based on BMD (TABLE).³

One standard deviation below normal equals a loss of 10% to 15% of bone mass. A patient with a T-score of –2.5 has lost >25% of bone mass. Although patients with osteoporosis have the highest probability of fracture, studies have consistently found that patients with osteopenia can also sustain fractures. Therefore, assess other risk factors for bone loss (identified below) when evaluating a patient.^4-6

FAST TRACK

An online assessment tool, FRAX, calculates the 10-year probability of major osteoporotic fracture based on risk factors and femoral neck T-score.

A useful assessment tool. To identify patients at risk for fractures, the World Health Organization offers a Web-based Fracture Risk Assessment Tool (FRAX).⁷ This tool, which takes into account risk factors and a femoral neck T-score, helps predict the 10-year probability of a hip or other major osteoporotic fracture. FRAX recognizes the following risk factors: age, sex, weight, height, fracture history, parental history of a hip fracture, cigarette use, long-term use of glucocorticoids, rheumatoid arthritis, concomitant disorders known to cause secondary osteoporosis, and daily alcohol consumption. If a T-score is not available, a patient’s body mass index may be used to estimate fracture risk. This free tool is available at www.shef.ac.uk/FRAX. Fracture risk calculation may also help resolve questions about when to initiate treatment for patients with osteopenia.

TABLE
Defining bone integrity by bone mineral density

Normal	BMD is within 1 SD of that of a young normal adult (T-score ≥–1.0)
Low bone mass (osteopenia)	BMD is between 1.0 and 2.5 SD below that of a young normal adult (T-score between –1.0 and –2.5)
Osteoporosis	BMD is at least 2.5 SD below that of a young normal adult (T-score ≤–2.5)
BMD, bone mineral density; SD, standard deviation.
Source: WHO Study Group on Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis. WHO Technical Report Series, No. 843. 1994.³

Undertreatment of osteoporosis is also a significant problem

A study based on National Health and Nutrition Examination Survey data reported that fewer than 20% of women and men who had sustained an osteoporotic fracture or were at high risk for fracture were being treated with antiresorptive agents.⁸

National Osteoporosis Foundation (NOF) guidelines⁹ recommend considering treatment for postmenopausal women 50 years of age or older who exhibit the following:

A hip or vertebral fracture
T-score ≤–2.5 at the femoral neck, total hip, or spine after appropriate evaluation to exclude secondary causes
Low bone mass and a 10-year probability of hip fracture ≥3%, or a 10-year probability of any major osteoporosis-related fracture ≥20%, based on the FRAX calculation.

The NOF Clinician’s Guide to Prevention and Treatment of Osteoporosis is available at http://www.nof.org/files/nof/public/content/file/344/upload/159.pdf.