Mary Beth Humphrey, MD, PhD, FACP, is concerned that patients with rheumatic diseases who have already experienced a bone fracture are being undertreated for osteoporosis. Dr. Humphrey is a practicing rheumatologist at the Oklahoma University Health Sciences Center, director of the Rheumatology, Immunology and Allergy program within the Oklahoma University School of Medicine. She runs a lab investigating aspects of rheumatic disease, including osteoporosis and osteoimmunology.
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Her concern with patients being undertreated for osteoporosis is based on a series of studies that suggest:
- Only a small percentage (7% in a study on vertebral fractures) of adult patients who present with fractures, such as vertebral and hip fractures, begin anti-osteoporosis medication;1 and
- Anti-osteoporosis treatment goes down and incidence for hip fracture goes up when a significant news report publishes information about drug holidays or side effects of anti-osteoporosis treatment.2
“I think we are missing opportunities to treat patients who are presenting with fractures—this should be our most important group to treat,” Dr. Humphrey says.
Alternatively, a recent study suggests some physicians may be overtreating patients with anti-osteoporosis medications in the absence of osteoporosis.3
“Overtreatment [of osteoporosis] is something we worry about,” Dr. Humphrey says. She notes it’s reassuring to read in this study that rheumatologists were among the physicians with the lowest rates of overtreatment. However in the study, family practitioners were found to be overtreating patients without osteoporosis, defined as a T score < -2.5 or a Fracture Risk Assessment Tool (FRAX) analysis with increased risk of fracture. All physicians, including rheumatologists, should be aware of this risk.
Talk About Bone Health
Dedicated discussion between rheumatologists and their patients about osteoporosis needs to target a patient’s specific risk and begin with screening. Dual-energy X-ray absorptiometry (DXA) is the preferred method to test bone density; however, insurance coverage for it varies.
Dr. Humphrey says FRAX can also be effective in determining if a patient is at low, moderate or high risk for bone fragility and fracture caused by osteoporosis.
She suggests screening results should be discussed with the patient in the context of established guidance, such as the ACR’s 2017 Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis, which Dr. Humphrey co-authored.
“It’s easy to pull up the guideline electronically while talking to a patient to guide discussion based on osteoporosis risk, lifestyle choices and comorbidities, which can dictate treatment options,” Dr. Humphrey says.
Strategize for Optimal Treatment
After a rheumatologist identifies a patient is at high risk for fracture, they should conduct separate discussion about medications. Important points to cover with patients in this discussion include:
- Any previous fractures, including the fracture type and severity;
- Preferred medication options; and
- Length of therapy.
Several different classes of anti-osteoporosis drugs exist. These treatments include oral bisphosphonates; IV bisphosphonates; parathyroid hormone analogs, such as teriparatide and abaloparatide; and denosumab. Additional options include raloxifene for postmenopausal women when other medications are not deemed appropriate.
Duration of therapy is very important to discuss for the ongoing assessment of benefits and risks associated with anti-osteoporosis medication, Dr. Humphrey stresses. “We have seen many physicians recommend drug holidays, but research has indicated that patients on these drug holidays will revert back to an osteoporotic bone mineral density over five years. So monitoring is important to help indicate when therapy should be restarted,” she says.4
Help Patients Do Their Part
It’s important to educate patients about how anti-osteoporosis medications work and their risks, such as dental issues that occur late in therapy, Dr. Humphrey notes.
“We remind patients while on certain anti-osteoporosis [therapies], including bisphosphonates and denosumab, to get in to see the dentist regularly and remind the primary care physician and dentist they are on these meds,” she says. “The dental provider can take conservative preventive measures, such as a root canal to avoid tooth extraction, when possible.”
Additionally, it’s important to talk to patients about other medical risk factors, such as poorly controlled diabetes, high-dose steroids and chemotherapy, associated with osteonecrosis of the jaw, which is rarely seen with anti-osteoporosis treatments.
“All patients have the power to make important lifestyle decisions that can protect their bone health, such as smoking cessation, reduced alcohol intake and adherence to autoimmune disease control, particularly for patients with rheumatoid arthritis,” Dr. Humphrey says. “Rheumatologists can provide regular reminders about these actions to significantly improve a patient’s osteoporosis risk management and overall bone health.”
Carina Stanton is a freelance science journalist based in Denver.
- Barton DW, Behrend CJ, Carmouche JJ. Rates of osteoporosis screening and treatment following vertebral fracture. Spine J. 2018 Aug 22. pii: S1529-9430(18)31092-1.
- Jha S, Wang Z, Laucis N, et al.Trends in media reports, oral bisphosphonate prescriptions, and hip fractures 1996–2012: An ecological analysis. J Bone Miner Res. 2015 Dec;30(12):2179–2187
- Hall SF, Wright NC, Wolinsky FD, et al. The prevalence of overtreatment of osteoporosis: Results from the PAADRN trial. Arch Osteoporos. 2018 Sep 28;13(1):103.
- Black DM, Schwartz AV, Ensurd KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment: The fracture intervention trial long-term extension (FLEX): A randomized trial. JAMA. 2006 Dec 27;296(24):2927–2938.