A Balancing Act: Tips to Ensure Optimal Screening & Treatment for Osteoporosis

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.

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.