Management Of Osteoporosis In Women Research Articles

Predicting the probability of osteoporotic fracture risk in men versus women: do we need specific reference interventional thresholds for men?

BackgroundGender differences in the diagnosis and treatment of osteoporosis is a relatively common phenomenon, particularly amongst those patients under 80 years of age presenting with fragility fractures. The clinical implications of these findings are that strategies, which tend to focus on osteoporosis management in women, should also pay enough attention to osteoporosis in men. However, there have been questions whether there is a gender difference when setting intervention thresholds for osteoporosis management. This work was carried out aiming to determine the fracture probabilities calculated by FRAX at which therapeutic intervention in older men and women can be considered.ResultsAssessment of fracture risk probability thresholds in men revealed that for hip fractures, ROC was 0.754 (95% CI: 0.69–0.817). The sensitivity was 80.5% for threshold probabilities of 2.5%. For the major osteoporosis fracture, ROC was 0.828 (95% CI: 0.694–0.963). The sensitivity was 87.5% for threshold probabilities of 10%. Assessment of fracture risk probability threshold in women ROC was 0.760 (95% CI: 0.691–0.83). The sensitivity was 76.1% for threshold probabilities of 3%. For major osteoporosis fracture, ROC was 0.848 (95% CI: 0.784–0.912). The sensitivity was 87.3% for threshold probabilities of 15%.ConclusionOperational aspects of osteoporosis management should consider gender specific fracture thresholds. Interventional thresholds were found to be different in men compared to women. This helps to optimise fracture prevention in older men.

P-676 Bone health in Australian women with early menopause: a 23-year longitudinal analysis

Abstract Study question What is the frequency of osteoporosis, fractures, and osteoporosis management in women with early menopause (menopause <45years; EM)? What factors influence osteoporosis, screening, and treatment? Summary answer Osteoporosis risk is 80% higher in women with early versus natural age menopause. Despite higher screening and treatment, gaps persist in managing EM bone health. What is known already A treatment gap in osteoporosis care exists, with low diagnosis (using dual X-ray absorptiometry, DXA), and primary or secondary fracture prevention. Women with EM have increased rates of osteoporosis. Clinical guidelines recommend screening with DXA and menopause hormone therapy (MHT) for most women with EM to reduce osteoporosis and fracture risk. However, studies suggest osteoporosis knowledge, guideline uptake and management adherence by clinicians and women is limited. Study design, size, duration The Australian Longitudinal Study on Women’s Health is a prospective longitudinal study of Australian women. This study uses the cohort of women born between 1946 – 1951, surveyed nine times between 1996 – 2019. Data from Australian administrative health records including the Pharmaceutical Benefits Scheme (PBS) (MHT, Bone specific agents; BSA) and Medicare benefits schedule (DXA) was linked to survey data. Participants/materials, setting, methods Respondents with self-reported age of menopause were included. EM defined as above. T-test/chi-square used for comparisons at baseline (p < 0.05 indicates significance). Generalised estimating equations (GEE) for panel data explored longitudinal outcomes of osteoporosis, fractures, DXA rates, MHT use and BSA (in women with osteoporosis/fracture). Univariable regression was performed, and variables retained where p < 0.2, to form the multivariable model, and bootstrapping with 100 repetitions at 95% sampling of the original dataset to ensure robustness of results. Main results and the role of chance 8,603 women were included: 610 (7.1%) with EM. Mean (SD) baseline age was 47.6 (1.45) years in the entire cohort, and mean (SD) age of menopause was 38.2 (7.95) and 51.3 (3.04) years in women with EM and natural age menopause, respectively (P < 0.001). Overall, 421 (69.0%) women with EM had DXA screening, 305 (50%) had a fracture/osteoporosis, 474 ever used MHT (77.7%) and 142 (46.6%) used BSA. Using the multivariable model, women with EM had increased risk of osteoporosis (Odds Ratio (OR) 1.80; 95%CI 1.43,2.26), fractures (OR 1.48; 1.18,1.85), MHT use (OR 6.98; 5.78,8.43) and BSA use (OR 1.69; 1.24,2.32). In EM women, increasing age was associated with greater risk of osteoporosis / fracture (OR 1.09; 1.08,1.11), and MHT use did not significantly reduce this risk (OR 0.78; 0.55,1.11). In EM women, age (OR 1.32; 1.12,1.15), BMI (OR 0.94; 0.91,0.96), current smoking (OR 0.51; 0.35,0.74) and inner (OR 0.69; 0.52,0.91) or outer regional (OR 0.66; 0.46,0.95) residential location were associated with DXA screening. In EM women, increasing age (OR 1.15; 1.13,1.18) and lower BMI (OR 0.91; 0.86,0.95) were associated with BSA use. Limitations, reasons for caution Survey data were self-reported by participants, and fracture questions were not included in the 2001 survey. PBS data was only available from 2004, and hospital admissions data for all of Australia was only available from 2007. Wider implications of the findings Osteoporosis and fractures affect a significant number of women with EM. Focus must be made on improving screening and treatment of these women. Trial registration number N/A

Personalized medicine approach to osteoporosis management in women: integrating genetics, pharmacogenomics, and precision treatments

Personalized medicine approach to osteoporosis management in women: integrating genetics, pharmacogenomics, and precision treatments

Gender Disparities in Osteoporosis Screening and Management Among Older Adults.

One in two women and one in four men experience an osteoporosis-related fracture in their lifetime. Related morbidity and mortality rates are higher in men versus women. Current guidelines are inconsistent in the screening recommendations for osteoporosis in men. Examination of gender disparities in the management of osteoporosis-related fractures among Medicare enrollees is currently lacking. In this retrospective cohort study using 5% National Medicare claims data from January1, 2012 through December31, 2016, eligible patients who were at least 65years of age on the date of a new fracture episode were classified into two mutually exclusive cohorts on the basis of whether they received testing and/or treatment for osteoporosis in the 6-month period after the new fracture episode. The cohorts were defined on the basis of the National Committee for Quality Assurance (NCQA) quality measure "osteoporosis management in women who had a fracture." Patients were followed to identify the occurrence of subsequent fracture, all-cause mortality, and a composite outcome-defined as the first occurrence of either subsequent fracture or mortality. Logistic regression models were carried out to identify predictors of testing and/or treatment and time-varying survival analysis to identify the relationship between the presence of testing and/or treatment and patient outcomes. Of the 35,774 eligible patients, only 10.2% (12.1% women and 5.7% men) received osteoporosis testing and/or treatment within 6months after a fracture. The interaction between gender and fragility fracture was significant (P < 0.0001). Fragility fracture had greater adjusted odds of testing and/or treatment among men (adjusted odds ratio [AOR] 3.47; 95% CI 2.94-4.10) than women (AOR 1.65; 95% CI 1.53-1.79). Of patients who were eligible for the outcome assessment, 27.5% experienced a subsequent fracture, 23.2% died, and 44.3% experienced a composite outcome during follow-up. Patients who received testing and/or treatment had a significantly lower hazard of all-cause mortality (hazard ratio [HR] 0.57; 95% CI 0.50-0.65; P < 0.0001) and the composite outcome (HR 0.42; 95% CI 0.39-0.45; P < 0.0001), but no difference in the risk of subsequent fracture (HR 1.02; 95% CI 0.94-1.11; P = 0.6083). Men were found to have a significantly lower hazard of subsequent fracture (HR 0.69; 95% CI 0.64-0.73; P < 0.0001), all-cause mortality (HR 0.67; 95% CI 0.61-0.72; P < 0.0001), and the composite outcome (HR 0.69; 95% CI 0.65-0.73; P < 0.0001). Testing and/or treatment for osteoporosis among older adults with a fracture is poor in the Medicare fee-for-service population overall and worse for men compared to women. Receiving appropriate testing and/or treatment was associated with reduced mortality and the risk of composite outcome. Improving osteoporosis testing and/or treatment and reducing health disparities are essential for managing the clinical and economic burden of osteoporosis in the USA.

Management of Osteoporosis in Women with Breast Cancer

The screening, prevention and treatment of osteoporosis are similar in women with or without breast cancer. Breast cancer treatments, such as aromatase inhibitors, chemotherapy-induced ovarian failure and gonadotropin-releasing hormone antagonists all decrease estrogen levels, which in turn causes net bone resorption and bone loss. Bone loss over time will be of sufficient magnitude to cause some women to experience fractures. Thus, osteoporosis is an equation; the peak bone mass achieved by age 30 years minus the age-related and menopausal bone loss. Women should have their bone density measured by dual x-ray absorptiometry scans every 2 years. As clinically indicated, women should receive anti-osteoporosis drugs such as zoledronic acid, denosumab or oral bisphosphonates.

Women's Values and Preferences Regarding Osteoporosis Treatments: A Systematic Review.

Several treatments are available to reduce the risk of fragility fractures associated with osteoporosis. The choice of treatment requires knowledge of patients' values and preferences. The aim of the present study was to summarize what is known about the values and preferences relevant to the management of osteoporosis in women. We conducted a comprehensive search of several databases for studies reported in any language that had included women who had already started or were about to start any pharmacological therapy for osteoporosis. Pairs of reviewers independently selected the studies and extracted the data. The results were synthesized narratively. We included 26 studies reporting on 15,348 women (mean age, 66 years). The women considered the effectiveness and adverse events equally, followed by the convenience of taking the drug and its effect on daily routine (less frequent dosing was preferred, the oral route was preferred, and the injectable route was preferred over oral if given less frequently). The treatment cost and duration were less important factors for decision making. Fear of breast cancer and fear of resuming uterine bleeding were common reasons for not choosing estrogen therapy. Calcium and vitamin D were viewed as safe and natural. Across the studies, the preferences were not affected by age, previous drug exposure, or employment status. Women starting osteoporosis medications value effectiveness and side effects equally and prefer medications given less frequently. Injectable drugs appear acceptable if given less frequently. More research on patient values and preferences is needed to guide decision making in osteoporosis.

Overuse and Underuse of Antiosteoporotic Treatments According to Highly Influential Osteoporosis Guidelines: A Population-Based Cross-Sectional Study in Spain.

Inappropriate prescribing of antiosteoporotic medications has been observed; however, the joint study of both overuse and underuse has barely been attempted. Spain, with its high utilization rates, constitutes a good example to assess differences in over and under use according to diverse highly-influential osteoporosis guidelines (HIOG) worldwide. We used data of a population-based cross-sectional study including 824 post-menopausal women ≥50 years old living in the city of Valencia, Spain and aimed to estimate the percentage of women eligible for treatment, and the proportion of overuse and underuse of antiosteoporotic treatment according to HIOG. The prevalence of antiosteoporotic treatment in postmenopausal women ≥ 50 in Valencia was 20.9% (95%CI:17.6–24.4). The type of antiosteoporotic drugs prescribed varied greatly depending on the medical specialty responsible of the initial prescription. When applying the HIOG, the percentage of women 50 and over who should be treated varied from less than 9% to over 44%. In real terms, from the approximately eight million women of 50 years old and over in Spain, the number eligible for treatment would range from 0.7 to 3.8 million, depending on the guideline used. A huge proportion of inappropriate treatments was found when applying these guidelines to the Spanish population, combining a high overuse (42–78% depending on the guideline used) and underuse (7–41%). In conclusion, we found that the pharmacological management of osteoporosis in women of 50 and over in this population combines an important overuse and, to a lesser extent, underuse, although the level of inappropriateness varied strikingly depending on the CPG used. It seems urgent to reduce treatment overuse without neglecting underuse, as is urgent an attempt to reach wider agreement worldwide regarding osteoporosis management, in order to facilitate appropriate treatment and development of policies to reduce effectively treatment inappropriateness.

Management of osteoporosis in women after forearm fracture: Data from a French health insurance database

IntroductionDespite reliable diagnostic methods and effective drugs, the prevention and management of osteoporosis seems insufficient in France. We evaluated bone mineral density (BMD) assessment and prescription of anti-osteoporotic drugs after forearm fracture in women. MethodsWe used a health insurance database for outpatients from private clinics in a French population of more than 500,000 inhabitants. Medical expenses were analyzed for women 50years of age or older who had a forearm fracture between August 1, 2010 and June 30, 2012. ResultsWe identified 250 forearm fractures in women during the study period. In total, 12 women (4.8%) underwent BMD assessment before the fracture and were not taken into account in the analysis. For the 238 others, 24 (10.1%) had undergone BMD assessment at a median of 4months after the fracture. A total of 32 women (13.4%) received an anti-osteoporotic drug at the time of the fracture and 14 of 206 untreated women (6.8%) received an anti-osteoporotic drug at a median of 3.8months after the fracture. Receipt of an anti-osteoporotic drug was more frequent for women with than without BMD assessment after the fracture (8/19 [40.1%] versus 6/187 [3.2%]; P<0.005). ConclusionThis work, performed in a large sample, suggests that only 10% of women 50years of age or older in France undergo BMD assessment after a forearm fracture and that BMD assessment is associated with anti-osteoporotic drug prescription.

Are you aware that you are being evaluated?

During my 3-hour drive home that evening, I realized that it is imperative that my business partner and I become more knowledgeable about the CMS star ratings. We must reevaluate our practice to see how we are performing day to day in providing quality care to patients. We must implement new practice initiatives to improve those performance measures on which our practice may be evaluated. When I returned home, I went to the CMS website and reviewed the star rating information. I also downloaded a document that discussed the proposed methodology for 2014 star ratings.1

Raloxifene May Have Further Benefits in Women on Hemodialysis

Dear Editor, Saito et al. report on the possible beneficial effects of raloxifene on bone metabolism in women on hemodialysis (1). We commend the authors on their investigation of treatment in this difficult group. Currently there are limited options available for osteoporosis management in women on hemodialysis which is a significant concern given that the fracture rate for these women is quadruple that of women in the general population (2). The role of postmenopausal osteoporosis in higher fracture rates in women on dialysis is increasingly recognized (2). The frequency of early menopause, menstrual disturbance and hypo-estrogenic states are also higher in women on dialysis. (3) Menopause is a ‘window of vulnerability’ for depression in women, women on haemodialysis are particularly at risk of mental illness. A recent study found the prevalence of mental illness to be 30.3% in patients on hemodialysis (4). Mental illness, particularly depression has been found to be a predictor of reduced quality of life, increased morbidity and mortality (4). Whilst psychotropic medication can be used in hemodialysis patients, antidepressants and antipsychotic medications are independent risk factors for osteoporosis (5). Whether this risk is magnified in dialysis patients is not currently known. Both estrogen therapy and SERMs have been investigated for their benefit on bone turnover in hemodialyis patients, they may well have further benefits. The mood enhancing effects of estrogen are well known (6). We have performed clinical trials showing improvement in psychotic symptoms with adjunctive transdermal estrogen therapy. Our recent dose finding study found raloxifene 120mg to also be effective at reducing positive and negative symptoms of psychosis in postmenopausal women. We are currently conducting larger clinical trials examining the effect of raloxifene on psychosis in pre and postmenopausal women. Given the mortality risks of mental illness and osteoporosis in women on hemodialysis it would be helpful if drug regimens that improve both conditions could be developed. Hopefully raloxifene will fulfill this role. We keenly await further data from Saito and Co. regarding the longer term effects of raloxifene in women on dialysis and particularly the impact on fracture risk.

The cost effectiveness of zoledronic acid 5 mg for the management of postmenopausal osteoporosis in women with prior fractures: evidence from Finland, Norway and the Netherlands

Objective:This study was conducted to assess the cost effectiveness of zoledronic acid 5 mg as a first-line treatment for the secondary prevention of fragility fractures in women with postmenopausal osteoporosis in Finland, Norway and the Netherlands.Methods:A discrete-event, individual-patient computer-simulation model was used to compare the cost effectiveness of zoledronic acid with that of basic treatment (calcium and vitamin D) and commonly prescribed bisphosphonates in postmenopausal women aged 50–80 years who have experienced one previous fracture and have a bone mineral density T-score of −2.5.Results:The cost per quality-adjusted life-year (QALY) gained with zoledronic acid compared with basic treatment ranged from being cost saving in all age groups in Norway, to costing approximately €19,000 in Finland and €22,300 in the Netherlands. Compared with the other branded bisphosphonates, zoledronic acid was cost saving in many scenarios, including all age groups in Finland. In Norway, zoledronic acid dominated branded risedronate and ibandronate in all age groups and dominated or had incremental cost-effectiveness ratios (ICERs) of up to NOK83,954 per QALY gained compared with branded alendronate. In the Netherlands, zoledronic acid dominated branded intravenous ibandronate in all age groups; compared with branded risedronate and oral ibandronate, zoledronic acid dominated or had ICERs of up to €4832 per QALY gained; compared with branded alendronate, it had ICERs of up to €48,383 per QALY gained. In all three countries, zoledronic acid may be cost effective compared with generic alendronate when patient compliance with drug therapy is taken into account. Sensitivity analyses showed that the model was robust to changes in key values. The main model limitations were the lack of real-life compliance and persistence data, and lack of country-specific data for some parameters.Conclusions:Using local or commonly used thresholds, this analysis suggests that zoledronic acid would be a cost-effective first-line option compared with other branded bisphosphonates and, in some scenarios, compared with generic alendronate, for the secondary prevention of fractures in women with postmenopausal osteoporosis in Finland, Norway and the Netherlands.

Clinical management of osteoporosis in women with a history of breast carcinoma

Osteoporosis is a skeletal disorder that is characterized by low bone mass and compromised bone strength. Fractures are the clinically important consequence of osteoporosis and result not only in disability but also in excess mortality. Women who have a history of breast carcinoma may represent a unique population for whom screening and treatment for osteoporosis should be modified. A review of the English literature was performed that included original, review, consensus, and statement articles that were identified through Medline or National Institutes of Health-related links. According to the literature, osteoporosis constitutes a major public health problem. Approximately 55% of the U.S. population > or = 50 years of age has low bone mass (osteopenia or osteoporosis). Annually, > 200,000 women in the U.S. are diagnosed with breast carcinoma. Due to the high prevalence rates of both low bone mass and breast carcinoma in women, these two diseases commonly coexist in the same individuals. Women with a history of breast carcinoma may be at increased risk of developing bone loss and fragility fractures as a consequence of antineoplastic therapies. The majority of women treated for early-stage breast carcinoma do not develop recurrences, as a result of recent advances in therapy. Ensuring the diagnosis, prevention, and treatment of long-term toxicities and comorbid conditions like osteoporosis in breast carcinoma survivors is a serious concern and is of increasing importance. In this article, the authors address the evaluation and treatment of osteoporosis in women who have a history of early-stage breast carcinoma.

Prevention and management of osteoporosis in women with breast cancer and men with prostate cancer.

Advances in cancer treatment have resulted in improved life expectancies for survivors of breast and prostate cancer. As the number of cancer survivors grows, the long-term side effects of treatment play an increasingly prominent role in the routine care of these patients. Due to similar management approaches, survivors of breast and prostate cancer are at increased risk for osteoporosis. This review summarizes the prevention and management of osteoporosis and osteopenia resulting from cancer treatment in survivors of breast and prostate cancer.

Management of osteoporosis in women with peripheral osteoporotic fractures after 50 years of age: a study of practices

Objective. – To evaluate practices regarding the management of osteoporosis revealed by low-impact peripheral fractures in women older than 50 years of age. Methods. – Six orthopedic surgeons prospectively recruited patients presenting with their first low-impact peripheral fracture. Three months after the fracture, each patient’s usual primary-care physician provided information on management. Results. – The 132 patients (140 fractures) included in the study had a mean age of 73.8 years. Fracture sites in decreasing order of frequency were the wrist (29%), the hip (28%), the ankle (19%), the pelvis, the humerus, and the leg. Data on management by the primary-care physician were available for 106 patients. Fifty patients (50/106, 47%) were given a diagnosis of osteoporosis by their primary-care physician and 38 (38/106, 35%) received medications for osteoporosis. Conclusion. – In two-thirds of patients, a valuable opportunity for using the effective treatments available for osteoporosis was lost. Given the high risk of further fractures in this population, our finding is of great concern.

Management of osteoporosis in women aged 50 and older with osteoporosis-related fractures in a managed care population.

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.

Fracture risks for women in long-term care: high prevalence of calcaneal osteoporosis and hypovitaminosis D.

To determine the prevalence of osteoporosis as assessed by peripheral bone mineral density (BMD) in women living in a nursing home, to determine how many women with low BMD had received a diagnosis of osteoporosis, to assess the prevalence of vitamin D deficiency, and to seek reasons for vitamin D deficiency. Measurement of calcaneal BMD and serum 25-hydroxyvitamin D. Skilled nursing facility. Forty-nine women aged 68-100 years. Bilateral calcaneal BMD was measured by dual-energy x-ray absorptiometry and serum 25-hydroxyvitamin D by radioimmunoassay. Medical records were reviewed to assess osteoporosis risk factors, previous documentation of osteoporosis or malabsorption, and supplemental vitamin D intake. Fifty-nine percent of the 39 women with calcaneal BMD measurements (95% confidence interval [CI] 44-74%) exhibited calcaneal osteoporosis (T score < -2.5). Sixty percent (95% CI 46-74%) had 25-hydroxyvitamin D levels of 20 ng/ml or less, which is associated with secondary hyperparathyroidism; only 4% of women had levels above 30 ng/ml, recently recommended as optimal. Vitamin D status was suboptimal even in most women taking multivitamins. Osteoporosis was documented in the records of 17% of 23 women with calcaneal osteoporosis. Osteoporosis was prevalent but poorly documented in women living in the nursing home. Peripheral BMD measurements have the potential to improve the recognition and management of osteoporosis in women in long-term care facilities. The high prevalence of vitamin D deficiency, even in those taking multivitamins, indicates that practical new approaches for vitamin D repletion in this population are urgently needed.

Hormone replacement therapy and fractures in older adults.

Estrogen deficiency in women is associated with accelerated bone loss, and estrogen replacement therapy has been proven to be effective in preventing osteoporosis and fractures in postmenopausal women. The introduction of selective estrogen receptor modulators that have an estrogen-like effect on the skeleton but have a different pattern of effects on other tissues may have an important role in the management of osteoporosis in women in the near future. In men, androgen deficiency has been shown to be associated with osteoporosis. Although androgen replacement in hypogonadal men may decrease bone resorption and increase bone mass, long-term placebo-controlled trials are needed to better define the benefits and risks of such therapy before it can be recommended. Sex hormone deficiency is linked to the development of osteoporosis in both women and men. In women, hormonal replacement by estrogen or the newly developed selective estrogen receptor modulators may prevent the development of osteoporosis and its related fractures. In men, there is early evidence that testosterone replacement therapy may enhance bone mass in hypogonadal men.

Expectations for alendronate in gynecology

Although the effect of alendronate is slightly less effective than that of hormone replacement therapy in terms of the short-term increase in bone mineral density, alendronate excels with respect to long-term benefits, often persisting after discontinuation of treatment. Alendronate is more effective than hormone replacement therapy in preventing femoral neck fractures and is thus indicated for the long-term prophylaxis of postmenopausal decreases in bone mineral density and for the management of osteoporosis in women who have fractures or an increased fracture risk. Alendronate may become a treatment of first choice for osteoporosis in postmenopausal women. As further evidence of cardiovascular benefits of alendronate becomes available, alendronate is expected to contribute to the overall health care of middle aged and elderly women.