I don’t know about you, but I find osteoporosis frustrating. So many questions. When and who should I screen? When and who should I re-screen? How concerned should I be about possible side effects of various bisphosphonates? Are calcium supplements more harmful than helpful? And every time I feel I’m getting a handle on these questions, a new study comes out with a different spin on things.
So what are busy clinicians to do? In hope of adding a little clarity, here are a few tips reflecting current expert opinion. Two disclaimers: (1) one can find other opinions on most of these issues and (2) some of these tips may be outdated two years from now. Or even two months from now.
- There is no specific T-score on BMD testing that accurately predicts the risk of fracture, though the risk of fracture does tend to increase as T-scores decrease.
- It is reasonable to screen all women ages 65 and older with BMD testing.
- It is reasonable to screen all women who have sustained a fragility fracture.
- It is reasonable to screen women under age 65 if they have risk factors for fracture (chronic steroid therapy, smoking, excess alcohol, rheumatoid arthritis, family hx of fractures, low body weight).
- All women at risk of fracture should be advised to stop smoking, decrease their alcohol intake, eat a diet rich in calcium and vitamin D (e.g. oily fish, eggs, and vitamin-D-fortified foods), and exercise.
- Oral calcium supplements are controversial, since some studies show they can increase the risk of coronary artery disease.
- In the interests of full disclosure, it is actually not clear that dietary calcium makes much difference. A December 2012 study in the Journal of Clinical Endocrinology and Metabolism (JCEM) found no correlation between dietary calcium intake and bone density. At least no studies have found harm from consuming a high calcium diet. Not yet anyway.
- Oral vitamin D (800-1,000 units per day) is advisable if vitamin D levels are low.
- Who should be considered for pharmacotherapy? There is good consensus to treat women who have sustained fragility fractures regardless of their BMD. Women with T-scores under -2.5 should probably be treated. For women with T-scores between -1 and -2.5, assess their risk of fracture by using the WHO FRAX calculator (http://www.shef.ac.uk/FRAX/). If the 10-year hip fracture risk is 3% or the 10-year risk of any osteoporotic fracture is 20%, pharmacotherapy is a reasonable choice.
- Bisphosphonates are generally recommended by most experts as first-line therapy when medication is needed. They have potential side effects, including exacerbating GERD symptoms, osteonecrosis of the jaw (rare), and atypical femur fractures (rare). A December 2012 JCEM study showed that most patients had hip or thigh pain for several months prior to their femur fracture, so development of such symptoms should prompt consideration of stopping the bisphosphonate.
- There have been no clinical studies demonstrating real-world differences among bisphosphonates based on half-life. Bisphosphonates with shorter half-lives have never been proven safer than those with longer half-lives.
- The presence of GERD is not a contraindication to the use of bisphosphonates.
- As far as when to repeat BMD testing for those under treatment, the earliest would be at two years. There is significant controversy about the appropriate interval for re-testing those not under treatment.
The above points are not intended to be a comprehensive review of all aspects of osteoporosis diagnosis and management. Also, I have intentionally avoided coming up with tips for screening and treating men, since this area has even more controversy than in women. As always, alternative viewpoints and comments are welcome.
Richard Fleming, MD