Current Approaches to the Prevention and Treatment of Postmenopausal Osteoporosis

Sheryl L. Follin, Laura B. Hansen

Disclosures

Am J Health Syst Pharm. 2003;60(9) 

In This Article

Abstract and Introduction

Abstract

Current approaches to the prevention, detection, treatment, and monitoring of postmenopausal osteoporosis are discussed.

In the United States, 44 million men and women ages 50 years or older have low bone mass or osteoporosis. The most devastating consequence of this disease is fractures. The assessment of osteoporosis risk includes determining risk factors, conducting laboratory and physical examinations, and measuring bone density and bone-turnover markers. Once risk has been established, nonpharmacologic strategies, such as exercise, appropriate dietary habits, and discontinuing tobacco and alcohol use, are helpful. Fall prevention and adequate intake of calcium and vitamin D are critical. When pharmacologic therapy is warranted, bisphosphonates have shown the greatest benefit in preventing bone loss and lowering fracture rates. Selective estrogen-receptor modulators and calcitonin are also options for prevention or treatment of osteoporosis. Estrogen should not be used for the sole purpose of osteoporosis prevention; however, short-term use is acceptable for women with vasomotor symptoms or in whom the benefits outweigh the risks. Parathyroid hormone may offer another treatment alternative.

A variety of pharmacologic options are available for patients with osteoporosis in whom lifestyle modifications have proven insufficient. Bisphosphonates are the mainstay of drug therapy.

Introduction

Sometimes referred to as the silent thief, osteoporosis is a disease that can rob the skeleton bank of its resources. It slowly and quietly causes microarchitectural deterioration of bone as people age, especially in women as they enter their postmenopausal years. In the United States, an estimated 44 million women and men ages 50 years or older have low bone mass (osteopenia) or osteoporosis.[1] The number of women ages 50 or older with osteoporosis is estimated at 8 million; those with low bone mass, at 22 million. By 2010, these numbers are predicted to increase to 9 million and 26 million, respectively. Osteoporosis is more common in Caucasians, Asians, and Hispanics than in African-Americans; half of all Caucasian women have osteoporosis or osteopenia by the end of the first postmenopausal decade.[2,3]

The most devastating consequence of osteoporosis is fractures, especially hip fractures. Over 1.5 million osteoporotic fractures occur annually in the United States, 300,000, of which are hip fractures.[4,5] Up to 90% of all fractures in the elderly can be attributed to osteoporosis.[6] Adults who have one fracture are 50-100% more likely to have another fracture.[7] The lifetime risk of fractures in a 50-year-old Caucasian woman is 40%.[4,5]

Osteoporotic fractures are associated with significant increases in mortality and morbidity.[8] Mortality rates among the elderly, one year after a hip fracture, range from 14% to 36%.[9] Compared with the general population, elderly women and men are two and three times as likely to die, respectively, after a hip fracture.[10] There is also evidence that women who suffer a clinical vertebral fracture have a lower survival rate. In the Study of Osteoporotic Fractures, there was a 23% greater age-adjusted mortality rate in women with one or more vertebral fractures.[11] Morbidity data show that, after a hip fracture, only 33-40% of people regain the ability to perform basic activities of daily living, 20% are nonambulatory, and 10-60% are unable to return home.[9] Although two thirds of vertebral fractures can remain asymptomatic, others may cause significant back pain, kyphosis, and height loss.[12] Patients with severe kyphosis can have gastrointestinal and respiratory problems due to intraabdominal compression and compression of the thoracic cavity.[13]

Fractures can cause substantial reductions in quality-adjusted life-years (QALYs). In one study, women 50 years of age or older with either a vertebral fracture or a hip fracture had significantly fewer QALYs than women without such fractures.[14] Women with a history of fractures were more likely to report limitations in activities of daily living, such as reaching over one's head, getting in and out of a car, putting on socks, and bending. Other studies have demonstrated reductions in survival and activities of daily living.[15,16,17,18] Social withdrawal, a negative self-perception, anxiety, and depression can be seen in women with osteoporosis. These psychosocial consequences can adversely impact overall health and quality of life.[19]

In 1995, an estimated $13.8 billion was spent in the United States for direct medical expenditures related to osteoporosis, including 400,000 hospital admissions, 2.5 million physician visits, and 180,000 nursing-home admissions.[20] In 2001, estimated direct costs for hospitalization and nursing-home care were nearly $17 billion ($47 million per day).[21]

It is important to identify patients at risk for osteoporosis and to implement lifestyle modifications and appropriate nonpharmacologic and pharmacologic interventions with the primary goal of fracture prevention. This article discusses current approaches to the prevention, detection, treatment, and monitoring of postmenopausal osteoporosis.

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