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0:00
I'm Mike Lewiecki,
Director of New Mexico Clinical
Research and Osteoporosis Center,
and Director of Bone
Health TeleECHO
at the University of New
Mexico Health Sciences Center.
Today I'm going to
talk to you about
current concepts for the management
of patients with osteoporosis.
0:24
Here is my disclosure.
0:28
The objectives of this
presentation are to
characterize the origins of the
osteoporosis treatment gap,
describe important clinical advances
in the management of osteoporosis,
and identify new and emerging concepts in
the care of patients with osteoporosis.
0:49
I'd like to begin by giving you a highly subjective
and brief history of osteoporosis that goes over
how we got to where
we are today.
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Here is a graph where the x-axis
represents going from then to now,
and the y-axis is
from worse to better.
This is how I think we've been doing
with the care of osteoporosis.
We've made great strides
and great progress,
but we currently have
many challenges.
I'd like to begin the
time frame in 1987,
which was when DXA was
first introduced for
clinical applications to measure
bone density in patients.
Following that, in 1994,
the WHO diagnostic
criteria were developed,
allowing us to diagnose osteoporosis in patients,
for the first time, before a fracture occurred.
This was followed a year later
by approval of alendronate,
for the treatment of
postmenopausal osteoporosis.
This was followed in
turn by mass marketing,
which allowed patients and health care
professionals to become more aware of osteoporosis,
and the potential for treatments
to reduce the risk of fractures.
In the United States,
we had the Bone Mass
Measurement Act
that allowed Medicare
to cover the cost of
bone density testing under
certain clinical situations.
This was followed by increasing
the availability of DXA.
We then had the U.S.
Surgeon General's report,
which emphasized that osteoporosis
was a major public health concern,
and challenged all of us to do a better job
of caring for patients with osteoporosis.
More drugs were approved.
We had more marketing
of these drugs,
and more marketing of
osteoporosis as a disease state.
This was followed by the development
of many clinical practice guidelines
which provided a
framework for physicians
to know how to manage
patients with osteoporosis.
FRAX was released,
which allowed us, for the first
time, to get a fully validated,
quantitative assessment of
absolute fracture risk.
The beginning of the downhill
slide on osteoporosis care,
I think followed the release of the
first Women's Health Initiative report.
It emphasized the
imbalance of benefits
and the risks of using
estrogen therapy.
I think it perhaps created
a little bit of mistrust
by women of institutions and
health care professionals,
who are now saying something different about
estrogen treatments than what they had heard before.
In the US, we subsequently
had, what I would call,
draconian reimbursement
cuts in DXA by Medicare,
to levels that were not
fully sustainable and
actually were less than the cost of
providing the procedure in many cases.
Reports started to come out about the risk of
osteonecrosis of the jaw with osteoporosis therapy.
Atypical femur fractures
were reported as well
with long term
bisphosphonate therapies.
Media reports often highlighted rare
possible side effects of medications,
and did not always explain the
balance of benefits and risks.
Fear of side effects
became rampant,
and many patients were
reluctant to start treatment
or continue treatment
because of this fear.
The concept of drug holidays came about
to help to address these concerns,
but often the idea of a drug holiday was
misunderstood and sometimes misused.
There were controversies
concerning calcium,
and whether that had adverse effects in
patients taking calcium supplements.
There were controversies
about vitamin D,
what appropriate replacement is
and what the ideal blood level is.
The bureaucracy of health care has become
quite daunting in many situations,
making it another challenge to
cure patients with osteoporosis.
Limited time for health care
encounters is a common issue.
Competing priorities,
especially for primary care physicians who
are taking care of many patient concerns,
sometimes osteoporosis is
not at the top of the list.
There are many competing guidelines
now that aren't always concordant,
which creates some confusion sometimes on
how to manage patients with osteoporosis.
Risk communication is a skill that can be
acquired with some dedication to learning,
but sometimes we don't always do
as effective a job as we'd like.
Ultimately, this has become a
crisis in the care of osteoporosis.
This is where we are today.
There is a large treatment gap in the
care of patients with osteoporosis,
