Treatment and Management of Osteoporosis

Summary

In this JAMA Clinical Reviews podcast, Dr. Mary McDermott interviews Dr. Suzanne Morin about osteoporosis, a condition causing low bone mass and increased fracture risk, especially in older adults. Dr. Morin discusses risk factors, including menopause, chronic conditions, and lifestyle factors. She outlines screening guidelines, diagnostic methods, and the importance of bone density tests. Treatment options, both pharmacological and non-pharmacological, are explored, with a focus on exercise, nutrition, and medications like bisphosphonates and anabolic agents. The podcast emphasizes the importance of early detection and personalized care to prevent fractures and improve patients' quality of life.

Takeaways

• 😀 Osteoporosis is a disease characterized by low bone mass and bone tissue deterioration, leading to increased fracture risk, especially in older adults and post-menopausal women.
• 😀 It affects both men and women, with 54 million Americans and over 200 million people worldwide living with osteoporosis.
• 😀 Risk factors for osteoporosis include chronic conditions like kidney or liver disease, inflammatory conditions, certain medications, low body weight, and physical inactivity.
• 😀 People over 50, especially those with risk factors, should be screened for osteoporosis, typically through a bone mineral density (DEXA) test.
• 😀 In post-menopausal women under 65, osteoporosis screening is recommended only if there are clinical risk factors present.
• 😀 Prior fractures, family history of hip fractures, smoking, and alcohol consumption also contribute to fracture risk, and should be considered in screening.
• 😀 Diagnosis of osteoporosis is based on clinical factors, such as previous fractures, or bone mineral density measurements showing a T-score of ≤ -2.5.
• 😀 Non-pharmacological treatments for osteoporosis include exercise, proper nutrition (especially calcium and vitamin D), smoking cessation, and reducing alcohol intake.
• 😀 Resistance training is specifically recommended to improve bone strength and reduce fracture risk in osteoporosis patients.
• 😀 First-line pharmacotherapy for osteoporosis typically includes bisphosphonates, with alternative medications like denosumab considered for those who cannot tolerate bisphosphonates.
• 😀 For patients on bisphosphonates, drug holidays are recommended after 3-5 years of use to mitigate risks like osteonecrosis of the jaw or atypical femur fractures.
• 😀 Anabolic agents, like parathyroid hormone analogs and romosozumab, are used for patients at high fracture risk or those who fail on anti-resorptive medications.

Q & A

What is osteoporosis and how does it develop?

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue, leading to skeletal fragility and increased risk of fractures. It typically develops in older adults, especially after the age of 50, when bone formation decreases compared to bone resorption. In women, it is often accelerated after menopause.

Who is at risk for osteoporosis aside from those with chronic kidney or liver disease?

Osteoporosis affects both men and women. Key risk factors include age (especially over 50), post-menopausal women, people with inflammatory conditions (like rheumatoid arthritis or inflammatory bowel disease), those who use medications impacting bone health (e.g., glucocorticoids), individuals with low body weight, and those who are sedentary.

Who should be screened for osteoporosis?

Screening is typically recommended for individuals over the age of 50, particularly those with clinical risk factors. For women over 65, universal screening with a bone mineral density test is recommended. Postmenopausal women under 65 should also be screened if they have clinical risk factors, and while some guidelines suggest screening men, there is insufficient data to support it universally.

What is the FRAX score, and how is it used in osteoporosis diagnosis?

The FRAX score is a fracture risk assessment tool that helps predict the likelihood of fractures in patients. It can be used with or without a bone mineral density (BMD) test and incorporates various risk factors such as age, history of fractures, and family history. It helps clinicians refine the assessment of fracture risk in people without osteoporosis or those not yet diagnosed.

What role does exercise play in the prevention of osteoporosis?

Exercise, particularly resistance training, is essential for maintaining bone strength. Resistance exercises help improve muscle strength, which in turn supports bone strength. Aerobic exercise is great for overall health but has less impact on bone density compared to resistance training.

What is the recommended intake of calcium and vitamin D for bone health?

The recommended daily intake of calcium ranges from 1,000 to 1,200 mg, depending on age and sex, and for vitamin D, it is 600 to 800 IU per day. It is preferred to obtain calcium through diet, while vitamin D may require supplementation, especially for those over 50, since it is harder to get enough from food alone.

What medications are commonly used to treat osteoporosis?

The treatment of osteoporosis typically involves anti-resorptive medications like bisphosphonates (e.g., alendronate and zoledronic acid) and anabolic agents like parathyroid hormone analogs (e.g., teriparatide). Bisphosphonates are usually the first-line treatment, but if contraindications are present, alternatives such as denosumab may be used.

What is a bisphosphonate drug holiday, and why is it recommended?

A bisphosphonate drug holiday is a planned interruption of treatment after 3-5 years, depending on the medication. This is recommended to reduce the risk of rare but serious side effects such as osteonecrosis of the jaw or atypical femur fractures. A holiday can last between 1 to 3 years, after which treatment may be resumed if fracture risk increases.

How is bone mineral density monitored during osteoporosis treatment?

Bone mineral density is typically measured at the beginning of treatment and then every 3 years to assess the effectiveness of therapy. An improvement in BMD is associated with a lower fracture risk, while a decline or no change may indicate the need for adjustment in treatment.

What are anabolic therapies, and when are they used in osteoporosis treatment?

Anabolic therapies, such as parathyroid hormone analogs (teriparatide) and sclerostin inhibitors (romosozumab), are used to increase bone formation. These therapies are generally reserved for individuals with very high fracture risk or those who have failed other treatments. They are used for a shorter duration (12-24 months) and have shown greater efficacy in reducing fractures for high-risk patients.