A Resource from the American College of Preventive Medicine
A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Osteoporosis Clinical Reference for more information.
Osteoporosis and Women’s Health
Sounding the Alarm on the Silent Disease with the Devastating Impact
Many women over age 50 already have low bone mass (osteopenia) -- about half of Caucasian, Asian and Hispanic women, nearly half of Native American and over a third of African American.
- About the same proportions will experience an osteoporosis-related fracture in their lifetime.
- Only 2 in 5 hip fracture patients regain pre-fracture level of independence; 1 in 5 requires nursing home
- Osteoporosis-related fractures place an enormous burden on individuals and their families, and on the health care system.
Osteoporosis is silent … until a fracture occurs, often with minimal trauma. Of great importance … some fractures occur with low bone mass before the threshold of osteoporosis is even reached.
Preventing Fractures Is the Goal
Osteopenia and osteoporosis can be identified and treated before fractures occur. But even after
- There are no warning signs or symptoms prior to a fracture -- a comprehensive risk assessment is the key.
The Good News: Although we can’t cure osteoporosis, we can change the balance of bone formation and loss, and increase the strength of bone. And, we have clear guidelines for doing so.
- Some risk factors are clearly defined, certainly low body weight (< 70 kg) and being postmenopausal.
- Bone density testing with dual energy x-ray absorptiometry (DXA) is the gold standard for assessment and monitoring.
- There are effective treatments, both lifestyle measures and an array of pharmacologic approaches.
- A fracture risk assessment tool is available to assist the decision regarding pharmacotherapy.
The Bad News: We have a significant problem with lack of awareness, and under-detection and under-treatment of low bone mass.
- Too many patients are not being given information about preventing bone loss.
- Too few are being assessed for risk, or tested for bone density.
- Once diagnosed, too few are being prescribed effective therapies.
- Once prescribed, about half are not compliant within a year.
The Challenge for Primary Care
To increase recognition and early intervention for low bone mass in women whose declining estrogen levels place them at increased risk for osteoporosis.
- Provide systematic risk assessment, evaluation of secondary causes, patient education on need to be proactive, assistance with a plan for lifestyle modifications and pharmacotherapy options, counseling and follow-up by staff.
- Organize practice systems according to the Chronic Care Model - to support self care, lifestyle modification, and sustained follow-up to assure compliance to therapy.
- Develop and train office teams to provide the counseling, support and follow-up.
- A guide for a brief consult that builds the foundation for effective management -- a comprehensive approach to assessment and treatment of osteopenia and osteoporosis.
Guide to a Brief Consult
Pre-Consult – Nurse or Medical Assistant
|1.||Address purpose of visit – plan to reduce fracture risk caused by low bone density (osteoporosis and osteopenia) |
|a. ||Key messages: |
|i.||Chronic nature of the condition - a gradual progressive process. |
|ii.||Key role of estrogen in women – increase risk with menopause.|
|iii.||Importance of calcium and vitamin D intake, regular exercise.|
|iv.||Difficulty rebuilding bone; key is preventing further loss.|
|v.||Fractures occur at low bone mass, usually before a diagnosis. |
|vi.||Fracture risk assessed best by considering both risk factors and bone density testing.|
|vii.||More risk factors and lower bone density means greater risk. |
|viii.||Treatment by lifestyle and medications.|
|2.||Assess Fracture Risk:|
Take a complete history to evaluate the patient's risk for osteoporosis or a fracture and to exclude secondary causes.
|b.||Review risk factors: [Table]|
|i.||Family history of osteoporosis or fracture, personal history of osteoporosis or fracture, body frame, older age|
|ii.||Lifestyle – smoking, drinking habits, weight bearing activity, diet (calcium, vitamin D), sunlight |
|iv.||Secondary causes if present - medical conditions, medications |
|c.||Discuss BMD testing|
|i.||No test: Discuss indications, decision to have test |
|1.||All women age 65 or older |
|2.||All postmenopausal with risk factors|
|3.|| Presence of a fracture to determine baseline BMD|
|4.||Premenopausal with ovarian dysfunction (clinical judgment) |
|ii.||Test completed: Postmenopausal |
|1.|| Classify - Normal (T ≥ – 1.0), Low Bone Mass (T between -1.0 and – 2.5), Osteoporosis (T ≤ -2.5)|
|Low hip BMD: Use US-adapted WHO Fracture Risk Model (FRAX™) to estimate 10-year risk of fracture|
|iii.||Test completed: Premenopausal |
|1.||Use race or ethnicity adjusted Z-scores in place of T-scores [≤ - 2.0 is "low BMD for age”]; WHO Model does not apply|
|d.||Physical exam to evaluate signs of osteoporosis and its secondary causes|
|i.||Order relevant blood and urine studies|
|3.||Advise changes to slow bone loss|
|a. || Increase dietary calcium (approximately 1,200 mg per day, including supplements)|
|i.||Estimate calcium content of patient’s diet:|
|b||Adequate intake of vitamin D (800 to 1,000 IU per day)|
|i.||Consider serum 25(OH)D test |
|c.||Regular weight-bearing and muscle-strengthening exercise|
|d.|| Avoiding tobacco use and excessive alcohol intake |
|e.||Fall prevention strategies, if a concern|
|f.||Medication to slow bone loss|
|4.||Assist with a plan of action to reduce fracture risk: |
|a. ||Non-pharmacologic approach: |
|i.||Use the 5A approach for lifestyle changes – smoking cessation, increasing activity, increasing calcium/vitamin D intake, reducing alcohol |
|1.||Ask – awareness of effect on bone health |
|2.||Assess – current behavior, willingness to change, self efficacy |
|3.||Advise – changes to make|
|4.||Assist – plan for changes, setting goals, anticipating barriers|
|5.||Arrange – follow-up to discuss progress|
|b.|| Pharmacologic approach:|
|i.||Review medication options; indications; pros and cons, administration, benefits and risks of each |
|1.||Bisphosphonates: First line, several options; concern regarding long-term uninterrupted use. |
|2.||Raloxifene: If bisphosphonates intolerable or contraindicated |
|3.||Calcitonin: Second line due to lack of long term efficacy data|
|4.||Estrogens: If menopausal symptoms|
|5.||Teriparatide: Severe cases prior to bisphosphonate therapy, or consider a 3-6 mos wash-out period following biphosphonates |
|1.||Ask – awareness of effect on bone health |
|ii.|| Anticipate compliance and persistence issues: Strategies for barriers|
|c.||Good clinical judgment should be the ultimate determinant of treatment decisions.|
|a.||Schedule follow-up visit if needed.|
|b.||Arrange BMD test if needed.|
|c.|| Order serum or urine tests based on clinical judgment -- calcium and/or vitamin D levels (if deficiencies), biomarkers to monitor response to therapy.|
|d.||Arrange counseling with nursing staff for diet, exercise, fall prevention, smoking cessation and/or alcohol reduction.|
|e.||Patients on medication should have bone density re-tested according to clinical judgment, but at least every two years.|
A Final Thought
Osteoporosis is a bigger problem than we care to admit. It is easy to overlook because it can progress for years with no problems. Then a fracture occurs. The impact is enormous, especially if it is a hip. It can disable patients and devastate families. Postmenopausal women are the target; they have the greatest risk for developing low bone mass and of suffering fractures. The fundamental goal is not only to identify the higher-risk patients who remain undiagnosed and untreated, but to heighten the awareness of all women to the propensity to develop low bone mass and the danger that it results in.
As women approach menopause, there must be a sense of urgency to heighten awareness, screen, discuss risk, measure bone density, increase calcium and vitamin D intake, and to begin pharmacologic therapy in a timely manner. Treatment is safe and efficacious, but it cannot wait; it must be initiated sooner rather than later. This is not a condition that can wait to be treated.
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