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A Must-Have List for Shared Decision Making in Osteoporosis

A Must-Have List for Shared Decision Making in Osteoporosis

Fractures due to osteoporosis are more common than the combination of stroke, myocardial infarction and breast cancer in postmenopausal women.

Left undiagnosed and untreated, osteoporosis-related bone fractures can lead to disability and the increased risk of mortality, according to Nelson B. Watts, M.D., and JoAnn E. Manson, M.D., DrPH, writing in the Dec. 12 issue of JAMA.

Women with osteoporosis may not know they have osteoporosis, that is, until their first fracture of an arm, leg, spine or pelvis area which are associated with an increased risk of future fractures, they wrote.

Drs. Watts and Manson outlined a few must-haves for physicians assessing patients for osteoporosis-related fractures:

  • Bone mineral density (BMD) measurement with dual-energy x-ray absorptiometry (DXA) is recommended for women at age 65 years and men at age 70 even when risk factors are not evident.
  • A clinical fracture risk assessment should be performed around age 50 years (or earlier for women in premature menopause).
  • Low body weight, early menopause (before about age 45 years), family history of osteoporosis, diseases (rheumatoid arthritis, inflammatory bowel disease, chronic obstructive pulmonary disease), and the chronic use of medications (glucocorticoids, proton pump inhibitors, selective serotonin reuptake nhibitors) increase fracture risk and a bone density assessment should be ordered sooner rather than later.
  • The Institute of Medicine (now the National Academy of Medicine) recommends calcium intake of 1,000 to 1,200 mg/d, ideally from foods; or calcium supplements when needed.
  • For vitamin D, 1,000 to 2,000 IU/d for patients at increased risk of osteoporosis. A 30 ng/mL or higher of serum 25-hydroxyvitamin D should be targeted.
  • Walking or a walking equivalent (treadmill or elliptical) for 30-40 minutes, at least 3 times per week is ideal.

In addition to vitamin intake and exercise, consider medication for high-risk patients to reduce fracture risk in the future. The National Osteoporosis Foundation recommends that medication be considered for patients with osteoporosis-related hip or spine fractures and those with a BMD standard deviation of 2.5 or more below the young normal mean.

The fracture risk calculator — FRAX —can be telling. If it indicates a 3% or more increased 10-year risk of hip fracture or a 20% or more increased 10-year risk of hip, humerus, forearm and clinical vertebral fracture — bisphosphonates should be considered. In specific cases, other treatments, such as raloxifene, could be considered for the spine.

Bisphosphonates work by accumulating in bone and after a period of treatment, a drug holiday could be acceptable in some patients on intravenous bisphosphonate treatment. High risk patients may continue to take oral treatment. Denosumab works differently and its effect is lost when the treatment stops.

But as with many conditions, adherence to treatment regimens is low for this condition, particularly for patients who do not exhibit symptoms. Providing accurate information that demonstrates the benefits of treatment can outweigh the risks and can aid in patient adherence long-term, the authors wrote.

 

 

References

Nelson B. Watts, MD; JoAnn E. Manson, MD, DrPH. "Osteoporosis and Fracture Risk Evaluation and Management Shared Decision Making in Clinical Practice," JAMA. Published online Dec. 12, 2016. DOI:10.1001/jama.2016.19087

 
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