Real-world evaluation and management of osteoporosis in postmenopausal women following distal radius fracture.

Strategies for the prevention and treatment of osteoporosis during early postmenopause

In a cluster randomized trial, we evaluated the effect of a multifaceted intervention (directed at both patient and primary care physician) on the rates of testing and treatment of osteoporosis in postmenopausal women within six months of their wrist fracture. Compared to usual care, women in the intervention practices were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments. Postmenopausal women with wrist fractures are at increased risk of future fragility fractures, yet they frequently do not receive evaluation and treatment for osteoporosis. We set out to evaluate a multifaceted intervention designed to improve management of osteoporosis in older women with recent wrist fractures. Cluster randomized trial of 270 women cared for in 119 primary care practices. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario, Canada. Family practices were randomly assigned to either the intervention or usual care. The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician, in addition to an educational package and letter to the women. The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture. The mean age of women was 69(10.9) years. The intervention increased the proportion of women started on osteoporosis medications (28% vs. 10%) of controls, adjusted OR 3.45, 95% CI, 1.58-7.56, p = 0.002) and the proportion who had a bone mineral density (BMD) test (53.3% vs. 26%) of controls, OR 3.38, 95% CI, 1.83-6.26, p < 0.001). In addition to the intervention, having a female physician was a predictor of increased testing and treatment rates. A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures.

Distal radius fracture: An opportunity for osteoporosis intervention

ABSTRACTObjective: The aim of this study was to evaluate osteoporosis diagnosis and treatment on the basis of medical history, at hospital discharge, and 6–12 months after discharge, as well as to assess the frequency of subsequent fractures in postmenopausal women with distal radius fracture.Research design and methods: A prospective, observational study of hospitalized women aged 55 years and older with an isolated distal radius fracture from minimal trauma. Subjects were recruited in 242 acute care hospitals in Germany.Outcome measures: Potential risk factors for osteoporosis, frequency of osteoporosis assessment, frequency of medication treatment and subsequent fractures 6–12 months after discharge.Results: Among 2031 patients we identified 652 appropriate postmenopausal women. Less than one-third of patient histories contained any bone density parameters, and only a minority of subjects (33%, 217) underwent bone density assessment while in hospital. Of these, 55% (119) were diagnosed with low bone density, yet only 30% of those were prescribed supplements (calcium/vitamin D) and/or specific osteoporosis medication (mostly bisphosphonates) at discharge. Six to twelve months after hospital discharge, the low rate of treatment had not changed substantially. In the interval, 4.3% had sustained a subsequent fracture from minimal trauma: 1.4% a distal radius fracture (0.3% a refracture) and 2.9% a hip joint or other fracture (not specified). A significant age difference between those with and without subsequent distal radius fractures was found ( p = 0.01) but not a significant difference between patients with or without osteoporosis medication ( p = 0.79), primarily because the case numbers were too small.Conclusions: A substantial proportion of postmenopausal women hospitalized with distal radius fracture were not sufficiently evaluated or treated for their potential risk of osteoporosis.

Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius. A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture. A search of the database identified 1,162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1,162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1,162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001). Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

Osteoporosis is the most common generalized disease of the skeleton, yet it is markedly undertreated in Germany. Selective literature review on the basis of the current German guidelines regarding the prevention, diagnosis, and treatment of osteoporosis in postmenopausal women and in men aged 60 and above, and a further search of literature published in the last three years. The indication for dual X-ray absorptiometry (DXA) measurement for the specific diagnosis of osteoporosis is derived from the patient's age, sex, history of fractures in the past, and further risk factors. The therapeutic threshold for osteoporosis has been set at a 30% predicted risk of osteoporotic fractures occurring within 10 years. The treatment consists of basic measures for fracture prevention combined with specific pharmacotherapy. The recommended drugs for the treatment of osteoporosis in postmenopausal women in particular are alendronic and ibandronic acid, raloxifen, risedronic acid, and strontium ranelate; the only approved drugs for men at present are alendronic and risedronic acid and teriparatid. Intensive patient education markedly improves the otherwise poor compliance with osteoporosis treatment.

When and how should bone mineral density be measured?

Bridging the Osteoporosis Quality Chasm

Although there is a great need for better therapeutic approaches to the patient who presents with a fracture, osteoporotic fractures will remain a condition that is more amenable to prevention than treatment. Hormone replacement therapy (HRT) is still considered by many the mainstay for the prevention and the treatment of posrmenopausal osteoporosis. However, there are several controversies regarding HRT, especially the duration of treatment and the risks/benefits ratio. Recent studies have challenged the assumption that HRT conveys real long-term beneficial effects. Raloxifene or other“selective estrogen receptor modulators” (SERMs) should progressively replace HRT in elderly women. Bisphosphonates have demonstrated a clearcut efficacy in the treatment of osteoporosis. Alendronate and risedronate have been the most extensively studied bisphosphonates under randomized controlled trials conditions. Both agents can reduce the risk of vertebral and hip fractures by one-fourth to one-half. However, oral bisphosphonates are not without gastro-intestinal toxicity and strict adherence to constraining therapeutic schemes is mandatory. Intermittent treatments are alredy in use. Weekly alendronate is as efficient as daily therapy and improves treatment compliance. Newer more potent bisphosphonates, such as oral ibandronate or intravenous zoledronic acid, will allow much less frequent administration. The anti-fracture efficacy of yearly zoledronic acid infusions is thus currently tested. On the other hand, bone-forming agents, such as daily subcutaneous injections of teriparatide (rhPTH 1-34) offer exciting perspectives for the treatment of severe osteoporosis despite the complexity of such therapy.Osteoporosis is now defined as a disease characterized by a low bone mass and a microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk. Osteoporosis is a major public health problem and the current risk for a 50-yr old white woman to suffer from a hip, a vertebra or a wrist fracture is around 40%, 17.5% of which will be hip fractures. The incidence of fractures is about three times lower in men than in women but the mortality due to hip fractures is higher in men. The cost of osteoporotic fractures is considerable and is estimated in USA to be more than 20 x 109 $ per year (1). The different patterns of bone loss are the result of distinct cellular mechanisms and it is probably an oversimplification to consider primary osteoporosis as a single disease (2). The inexorable age-related bone loss seen in both sexes is the result of gradual thinning of trabeculae brought about by declining osteoblast function. Thus the osteoblast teams become less and less capable of refilling the resorption cavities created by the osteoclasts, so the thickness of the trabecular packets, and consequently the trabeculae themselves, declines. By contrast, the rapid postmenopausal bone loss is viewed as osteoclast- mediated. As estrogens concentrations fall, the osteoclasts become hyperactive, penetrate too deeply into the trabecular plates, and perforate them. Once the trabecular plate is perforated, the template for new bone formation is lost, formation and resorption are uncoupled, i.e. do not occur at the same remodeling site, and tissue is rapidly lost. The trabeculae become more widely separated and intertrabecular connectivity is reduced. As if that were not enough, the postmenopausal increase in activation frequency of remodelling units adds to the deleterious effects of the hyperactive osteoclasts. The rapid disruption of trabecular microarchitecture that occurs after menopause has more deleterious consequences for bone strength that does simple trabecular thinning. This fact accounts for the sharp rise in crush fractures of the vertebrae, which are rich in cancellous bone, among postmenopausal women. In contrast, the incidence of fractures characteristic of“age-related” osteoporosis, such as hip fracture, increases exponentially after 65 years.Bone mineral density (BMD) as measured by dualenergy X-ray absorptiometry (DXA) is the most common method for the diagnosis of osteoporosis and the threshold of a T-score (number of SD below the «peak bone mass») less than –2.5 is now classically used to establish the diagnosis. The ability of DEXA to predict fracture risk in an untreated population is well-characterized (3). However, changes in BMD following therapeutic intervention do not appear to predict fracture reduction as well as BMD predicts fracture risk prior to treatment (4). There is a growing interest in biochemical markers of bone turnover for that matter.This article will briefly review the recent therapeutic developments and the perspectives for the prevention and treatment of primary osteoporosis. For more complete assessments, the reader is referred to recent reviews (5).

Keywords Raloxifene Alkaline Phosphatase Quantitative Ultrasound Speed of Sound Chronic Kidney Disease

Erratum to “Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013” [Maturitas 75 (2013) 392–396

Distal Radius Fracture Risk Reduction With a Comprehensive Osteoporosis Management Program

While increasing age, decreasing body mass index (BMI), and physical inactivity are known to increase hip fracture risk, whether these factors have similar effects on other common fractures is not well established. We used prospectively-collected data from a large cohort to examine the role of these factors on the risk of incident ankle, wrist and hip fractures in postmenopausal women. 1,155,304 postmenopausal participants in the Million Women Study with a mean age of 56.0 (SD 4.8) years, provided information about lifestyle, anthropometric, and reproductive factors at recruitment in 1996–2001. All participants were linked to National Health Service cause-specific hospital records for day-case or overnight admissions. During follow-up for an average of 8.3years per woman, 6807 women had an incident ankle fracture, 9733 an incident wrist fracture, and 5267 an incident hip fracture. Adjusted absolute and relative risks (RRs) for incident ankle, wrist, and hip fractures were calculated using Cox regression models. Age-specific rates for wrist and hip fractures increased sharply with age, whereas rates for ankle fracture did not. Cumulative absolute risks from ages 50 to 84years per 100 women were 2.5 (95%CI 2.2–2.8) for ankle fracture, 5.0 (95%CI 4.4–5.5) for wrist fracture, and 6.2 (95%CI 5.5–7.0) for hip fracture. Compared with lean women (BMI<20kg/m2), obese women (BMI≥30kg/m2) had a three-fold increased risk of ankle fracture (RR=3.07; 95%CI 2.53–3.74), but a substantially reduced risk of wrist fracture and especially of hip fracture (RR=0.57; 0.51–0.64 and 0.23; 0.21–0.27, respectively). Physical activity was associated with a reduced risk of hip fracture but was not associated with ankle or wrist fracture risk. Ankle, wrist and hip fractures are extremely common in postmenopausal women, but the associations with age, adiposity, and physical activity differ substantially between the three fracture sites.

This study describes the pattern of evaluation and management of osteoporosis in women aged 50 and older following an osteoporosis-related fracture, conducted as a retrospective cohort study using the administrative claims database of a managed care organization. Subjects were women, aged 50 years and older, with at least one osteoporosis-related fracture in the years 1996-1998 who were continuously enrolled in the system's health plan for at least 6 months prior to and post-fracture. Bone mineral density (BMD) testing, diagnosis of osteoporosis, and treatment with any Food and Drug Administration-approved medication for osteoporosis were identified using CPT, ICD-9, and National Drug Codes for the 6-month post-fracture period. There were 658 women with an osteoporosis-related fracture: 189 (29%) hip fractures, 226 (34%) wrist fractures, 127 (19%) vertebral fractures, and 116 (18%) rib fractures. In the post-fracture period, 46 (7%) underwent BMD testing, 153 (23%) had a diagnosis of osteoporosis, and 220 (31%) were treated with a medication approved for the prevention or treatment of osteoporosis. Of the 220 women with medication claims, 124 (56%) were for estrogen, and 96 (44%) were for other antiresorptive agents. Of the 507 women who did not have medication claims during the 6 months prior to the fracture, only 17% had new fills after the fracture. Management of osteoporosis in women aged 50 and older with fractures was inadequate, despite the high risk of subsequent fractures and recommendations that osteoporosis be the presumptive diagnosis. Significant opportunity exists for improvement in assuring post-fracture followup care.

What's New in Osteoporosis and Fragility Fractures.