{"id":293,"date":"2013-01-07T15:58:50","date_gmt":"2013-01-07T23:58:50","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=293"},"modified":"2014-02-19T13:34:47","modified_gmt":"2014-02-19T21:34:47","slug":"osteoporosis-tips-on-screening-and-treatment","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=293","title":{"rendered":"Osteoporosis: tips on screening and treatment"},"content":{"rendered":"<p>I don\u2019t 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 <!--more-->supplements more harmful than helpful? And every time I feel I\u2019m getting a handle on these questions, a new study comes out with a different spin on things.<\/p>\n<p>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 Two disclaimers: (1) one can find other opinions on most of these issues and (2) some of these tips may be outdated two years from now.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.<\/p>\n<ul>\n<li>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.<\/li>\n<li>It is reasonable to screen all women ages 65 and older with BMD testing.<\/li>\n<li>It is reasonable to screen all women who have sustained a fragility fracture.<\/li>\n<li>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).<\/li>\n<li>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.<\/li>\n<li>Oral calcium supplements are controversial, since some studies show they can increase the risk of coronary artery disease.<\/li>\n<li>In the interests of full disclosure, it is actually not clear that <em>dietary<\/em> calcium makes much difference. A December 2012 study in the <em>Journal of Clinical Endocrinology and Metabolism<\/em> (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.<\/li>\n<li>Oral vitamin D (800-1,000 units per day) is advisable if vitamin D levels are low.<\/li>\n<li>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 (<a href=\"http:\/\/www.shef.ac.uk\/FRAX\/\">http:\/\/www.shef.ac.uk\/FRAX\/<\/a>). 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.<\/li>\n<li>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 <em>JCEM <\/em>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.<\/li>\n<li>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.<\/li>\n<li>The presence of GERD is not a contraindication to the use of bisphosphonates.<\/li>\n<li>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.<\/li>\n<\/ul>\n<p>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.<\/p>\n<p>Richard Fleming, MD<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I don\u2019t 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<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6,13],"tags":[],"class_list":["post-293","post","type-post","status-publish","format-standard","hentry","category-formulary-pharmacy-issues","category-prevention"],"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/293","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=293"}],"version-history":[{"count":9,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/293\/revisions"}],"predecessor-version":[{"id":808,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/293\/revisions\/808"}],"wp:attachment":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=293"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=293"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=293"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}