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Current concepts for the management of patients with osteoporosis

Published on March 30, 2022   35 min

A selection of talks on Clinical Practice

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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.
1:03
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,

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