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Osteoporosis

Contributor: Marcy Bolster, MD

CASE 1:

A 68 year old woman presents to your office after retiring from New York City to South Carolina.  She is interested in discussing her bone health.  She notes that she had a DXA scan performed 3-5 years ago and was told that her bone density was slightly reduced and it was recommended that she take Calcium and Vitamin D supplementation.  She is otherwise healthy.  She has no specific complaints.   She has never sustained a fracture.  She denies tobacco or alcohol use.  She reports that her mother fell and broke her hip at age 88 years old.   Her current medications include Calcium with Vitamin D.  Her vital signs are normal and her physical examination is unremarkable.

For her evaluation you request routine laboratory testing to include a comprehensive metabolic panel (CMP), complete blood count (CBC), and serum 25 (OH) Vitamin D level, and all of these tests are normal.  A DXA scan is performed and reveals a T-score of L1-L4 to be -2.2, and the right femoral neck T-score is -2.6.

What are your recommendations to this patient? 

The DXA scan interpretation reveals that the patient has osteoporosis of the femoral neck T-score of -2.6.  She has a family history of osteoporosis with a maternal history of hip fracture.  She is thus at increased risk for fracture and should be treated with pharmacologic therapy. The options include anti-resorptive agents such as the bisphosphonates, raloxifene, and denosumab.  Raloxifene has been demonstrated to reduce the incidence of vertebral fractures however it does not reduce hip fracture incidence.  She is at highest risk for a hip fracture, thus a better choice would be either a bisphosphonate or denosumab therapy.  Considerations in the selection of an agent include route of administration (oral or intravenous bisphosphonate therapy or subcutaneous denosumab), frequency of administration and cost to the patient.

CASE 2:

A 72 year old woman presents to your office after retiring from New York City to Florida.  She is interested in discussing her bone health.  She notes that she had a DXA scan performed 3-5 years ago and was told that her bone density was slightly reduced and it was recommended that she take Calcium and Vitamin D supplementation.  She is otherwise healthy.  She has no specific complaints.   She has never sustained a fracture.  She denies tobacco or alcohol use.  She reports that her mother fell and broke her hip at the age of 88 years old.   Her current medications include Calcium with Vitamin D.  Her vital signs are normal and her physical examination is unremarkable.

For her evaluation you request routine laboratory testing to include a comprehensive metabolic panel (CMP), complete blood count (CBC), and serum 25 (OH) Vitamin D level, and all of these tests are normal.  The DXA scan interpretation reveals a T-score of L1-L4 to be -1.8, and the right femoral neck T-score is -1.9.  The FRAX scores corresponding to these T-scores indicate a 17% and 6.3% ten year probability of a major osteoporotic fracture and hip fracture, respectively.

How would you discuss the meaning of her DXA scan results and of the FRAX scores?

What are your recommendations to this patient?

The FRAX tool is a fracture risk assessment tool based on the patient's age, body mass index (BMI), tobacco use, alcohol use, presence of RA, use of glucocorticoids, prior history of fracture, parental history of hip fracture and presence of secondary causes of osteoporosis.  The FRAX tool can be applied to patients with osteopenia (T-score between -1.0 and -2.5) who have not been taking medications for osteoporosis (except for Calcium and Vitamin D).  It utilizes the femoral neck bone mineral density.  Fifty percent of fractures occur in patients with osteopenia, so the FRAX tool is helpful to identify those patients at higher risk for fracture.  The FRAX tool provides both a ten year probability prediction for a major osteoporotic fracture (hip, vertebral, forearm, humerus) and for a hip fracture.  Thus, two risk predictions are provided for a ten year probability for fracture.  For the United States, based on economic factors relating to the cost:benefit ratio, a 20%  or higher probability of a major osteoporotic fracture or a 3% or higher probability of a hip fracture at ten years would warrant pharmacologic therapy for osteoporosis.

Thus, this patient is at increased risk for a fracture and should be treated for osteoporosis.  She should be offered anti-resorptive therapy with the options of a bisphosphonate or denosumab.

Patient Care

  1. Recognize the approach to the evaluation of a patient with regard to his/her bone health
  2. Identify the risk factors for osteoporosis
  3. Recognize patients who should be screened for osteoporosis.
  4. Determine appropriate radiographic testing indicated
  5. Determine appropriate metabolic lab testing indicated
  6. Distinguish the appropriate medical management
  7. Determine the appropriate follow-up for the patient

Medical Knowledge

  1. Describe the cellular etiology for bone loss in adults
  2. Recognize the metabolic aberrations involved in secondary causes of bone loss
  3. Identify medications associated with accelerated bone loss
  4. Distinguish patients on glucocorticoids who require pharmacotherapy to prevent further loss of bone
  5. Describe the different pharmacologic therapy options including risks and benefits
  6. Identify the risks and benefits of pharmacotherapy for osteoporosis
  7. GI, osteonecrosis of the jaw, renal
  8. Identify the contraindications to osteoporosis pharmacotherapy
  9. Interpretation of a DXA scan
  10. Implementation of the FRAX tool for fracture risk assessment in appropriate populations

Interpersonal Communication

  1. Discuss risk factor modification with a patient
  2. Discuss fall prevention
  3. Discuss the results of a DXA scan with a patient
  4. Discuss the need for appropriate Calcium and Vitamin D supplementation with a patient, including dietary sources
  5. Discuss the importance of weight bearing exercise for bone health
  6. Discuss the risks and benefits of osteoporosis pharmacotherapy with a patient
  7. Explain infusion therapies including risks and benefits
  8. Use web-based resources to educate your patients
  9. Discuss treatment recommendations with other physicians involved in the care of the patient

Professionalism

  1. Recognize the importance of patient privacy, informed consent, equal care
  2. Demonstrate integrity and honesty in discussing patient care issues and management with the patient and family
  3. Provide adequate time and accessibility to address patient concerns

Problem-based learning

  1. Set learning goals in osteoporosis diagnosis and management
  2. Effectively use DXA scan results to manage patient care decisions and enhance education of the patient and the referring physician
  3. Integrate and apply the knowledge gained from history and exam, DXA scan reports and plain film radiography to make informed decisions about patient care
  4. Consider creating a quality improvement project to address bone health issues in patient care and physician management
  5. Develop a willingness to learn from errors and use errors in a constructive way to learn and to improve the systems for patient care
  6. Utilize web-based resources and evidence-based medicine to enhance learning about bone health and osteoporosis

Systems-based Practice

  1. Identify barriers to the delivery of optimal patient care for patients with low bone mass and offer improved ideas for delivering care
  2. Behave as a consultant to referring providers to enhance comprehensive care of patients in terms of bone health management
  3. Demonstrate the ability to collaborate with other health care providers in addressing a patient's bone health including orthopedic surgeons, physical therapists, and gynecologists
  4. Determine cost-effectiveness of management plans for addressing a patient's bone health
  5. Implement a cost-effective management plan for a patient with osteoporosis
  6. Demonstrate awareness of the impact of diagnostic and pharmacologic recommendations on the health care system, insurance companies and patient personal expenditures

References