Hi. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.
Osteoporosis affects more than 10 million Americans, and hip and vertebral fractures increase healthcare costs, risk for disability, nursing home placement, and death. Primary care physicians who treat older adults can prevent osteoporotic fractures through appropriate diagnosis and treatment. However, treatment raises a number of clinical questions. Who should be treated for osteoporosis and with what? Should bone mineral density (BMD) be retested in patients receiving treatment? How long should treatment continue?
A 2015 analysis published in BMJ suggested that the influence of the pharmaceutical industry on the international diagnostic criteria and treatment thresholds for osteoporosis and low BMD may lead clinicians to overestimate fracture risk, thereby prescribing drugs for women and men who derive little benefit from therapy. Although many clinicians repeat BMD testing every 1-2 years, test results rarely change treatment plans. Finally, the US Food and Drug Administration has cautioned that the use of bisphosphonates for more than 5 years may be associated with more harms than benefits, though it did not offer definitive guidance about when to discontinue these drugs temporarily or permanently.
A recently updated practice guideline produced by the American College of Physicians (ACP) and endorsed by the American Academy of Family Physicians sought to clarify some of these issues. Based on the results of a systematic review, the ACP concluded that the strongest evidence supports alendronate, risedronate, zoledronic acid, and denosumab to reduce the risk for hip and vertebral fractures in women with osteoporosis. For patients who can tolerate the gastrointestinal effects, generic alendronate is clearly the best bargain at $9 for a 1-month supply, compared with around $100 for generic risedronate or zoledronic acid and $1300 for brand-name Prolia®.
The ACP recommends that clinicians prescribe drugs for 5 years for women with osteoporosis and not repeat BMD measurements during therapy. Studies show that fracture risk is still reduced even in patients whose BMD does not increase or decreases during therapy. Overall, women treated for 10 years have no fewer nonvertebral fractures than those who stop therapy after 5 years. The guideline notes that women with either preexisting fractures or a low BMD after 5 years may benefit from continued treatment, but this is based on a post hoc analysis.
What about men? The US Preventive Services Task Force is currently updating its 2011 recommendations, which found insufficient evidence to screen older men for osteoporosis. The few studies of drug therapy in men mostly enrolled those diagnosed after a symptomatic fracture or incidentally on imaging performed for other reasons. As a result, the ACP guideline only recommends offering bisphosphonates to men with clinically recognized osteoporosis. Although the guideline doesn't address screening intervals for men, a 2016 cohort study showed that men over age 65 years who have normal or near-normal BMD are unlikely to benefit from rescreening for at least 9 years.
Finally, the guideline highlights three opportunities for family physicians to promote high-value care in osteoporosis: Don't frequently repeat testing in women with normal BMD because most will not progress to osteoporosis in 15 years; don't monitor BMD during the initial 5 years of drug therapy; and use generic osteoporosis drugs when possible.
This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.
Cite this: Overestimating Osteoporosis Prevalence Carries Its Own Risks - Medscape - Jun 07, 2017.