Early testing in healthcare has been a hot topic in recent months. For both infectious diseases and countless other health conditions. Timely testing is critical to faster diagnosis, prompter treatment, and, ultimately, better outcomes in many medical conditions, including osteoporosis.
As a physician who has the opportunity to care for patients living with this common, yet serious, disease, I understand first-hand the importance of early testing for osteoporosis. Individuals can have the condition for a long time and not even know it.
Osteoporosis is a silent disease
Osteoporosis is a silent disease. Patients often have no signs or symptoms until a fracture occurs.
Risk factors for osteoporosis include
- family history,
- being a woman.
Estrogen significantly affects the rate of bone loss. This is why osteoporosis is most common in postmenopausal women.
In the first 5-7 years after menopause, bone breakdown outpaces bone formation and bone loss often accelerates. Up to 20% of bone mass can be lost in a few years.[i]
Moreover, nearly 1 in 2 women over the age of 50 will experience a fragility, or low-impact, fracture.[ii] Unfortunately, there is still a disconnect that these fractures, such as those in the wrist or ankle, could be a warning sign for the disease. As a result, many patients go undiagnosed and untreated.
That’s why if your patients are women over 50, it’s important to prioritize bone health. Early identification and treatment of low bone density is the most effective approach in order to help patients avoid future painful fractures.
Testing for osteoporosis
A dual-energy X-ray absorptiometry scan, commonly referred to as a DXA scan, is a widely available, reliable bone density test. The test requires no special preparation and typically takes only 5 to 10 minutes.
For the results of the test, patients receive a T-score, which shows how much higher or lower their bone density is than that of a healthy young person, when bones are at their strongest. In general, the lower the bone density, the greater the potential risk of fracture.
Many women wait to obtain a bone density test until they are 65. However, if patients have clinical risk factors for bone loss or have experienced fractures, earlier testing is important.
Many women enter menopause with low bone mass already. Further, for some subsets of women, there is a risk for rapid bone loss of 10-20% over just five years.[iii]
For that reason, in my practice, I typically recommend a bone density test for anyone 50 and older with clinical risk factors. This is especially true for those who have already experienced a fracture.[iv]
The results of a DXA scan, combined with other risk factors including, but not limited to,
- family history,
- fracture history,
- excess alcohol,
will help assess future fracture risk and determine the need for potential treatment.
Understanding osteoporosis treatment options
Lifestyle changes, such as calcium, vitamin D, and fall protection, may be effective for some patients. However, when fracture risk is high, medications are needed.
Fortunately, there is a strong arsenal of treatment options. But, it is important to remember that what’s right for one person may not be right for another.
Prescription osteoporosis treatments come in several forms, including
They can be broken into two categories: antiresorptive and anabolic agents.
Antiresorptive treatments include the following:
- RANKL inhibitors,
- hormone therapies.
These types of medications help slow down the process of bone loss in order to preserve bone strength to reduce the risk of fracture.
Anabolic treatments include drugs such as PTH analogs and sclerostin inhibitors that do more than just maintain the bone that you already have. They help build new bone to reduce the risk of fracture.
Since studies have shown that postmenopausal women who have had a low-impact fracture are 6 times more likely to have another fracture within 1 year[v]. These bone builders, therefore, are an important option to help reduce the risk of fracture or subsequent fractures in this high-risk population.
Patients must play a role in their treatment decisions
It’s critical that patients play a role in their treatment decisions. This means that they must be fully educated on all their options, including the benefit-risk profile.
As a first step, I encourage my patients to visit the websites of the companies that make the treatments. And, I advise them to look at the information in an objective way. Patients should also always talk to their doctor to make sure they are balancing the risk and the reward.
As adults age, the impact of fractures can become more serious, increasing the risk of loss of independence and even dying prematurely. In fact, hip fractures have a 20% 1-year mortality in women (higher in men). And they cause 1 out of 5 patients to need care in a nursing home. They are the most serious type of fracture caused by osteoporosis and 75% of all hip fractures happen in women.[vi],[vii] Another recent study found that older adults who suffer a fragility hip fracture have an increased risk for death that lasts for more than 10 years after the fracture.[viii]
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All of these statistics reiterate the importance of being an empowered patient if they’ve been diagnosed with postmenopausal osteoporosis. They need to talk with their doctor about their bone health to fully understand their options. And they must choose a treatment where the benefits outweigh the risks.
Empowerment and Collaboration
The disconnect between osteoporosis and related fractures and subsequent treatment gap is alarming. However, there is a tremendous opportunity before us. By empowering more women to obtain bone density tests before a fracture occurs, even when they otherwise have no symptoms, we can ensure they take the necessary steps to protect bones by seeking treatment earlier.
I encourage my fellow physicians to engage in open dialogue with patients. Talking will help them fully understand all of the available postmenopausal osteoporosis treatment options. This means including both antiresorptives, which slow down bone loss, and anabolic medications that are designed to help boost the natural process that builds new bone.
With a concerted effort and greater collaboration between patients, primary care providers and specialists who more regularly treat postmenopausal women, such as rheumatologists and endocrinologists, we can help many more patients make effective treatment decisions earlier and reduce their fracture risk.
[i] National Osteoporosis Foundation – What Women Need to Know. Available at: https://www.nof.org/preventing-fractures/general-facts/what-women-need-to-know/. Accessed 05/26/2020.
[ii] National Osteoporosis Foundation. What is osteoporosis and what causes it? https://www.nof.org/patients/what-is-osteoporosis/. Accessed 05/21/2020.
[iii] Finkelstein J., et al. Bone mineral density changes during the menopause transition in a multiethnic cohort of women. J Clin Endocrinol Metab. 2008 Mar; 93(3): 861–868. Free access available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266953/. Accessed 05/21/2020.
[iv] National Osteoporosis Foundation. Bone Density Exam/Testing. https://www.nof.org/patients/diagnosis-information/bone-density-examtesting/. Accessed 06/01/2020.
[v] Simonelli C, et al. Evaluation and Management of Osteoporosis Following Hospitalization for Low-Impact Fracture. J Gen Intern Med. 2003 Jan;18(1)17-22. Free access available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494813/. Accessed 05/21/2020.
[vi] Leibson CL, et.al. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 2002;50(10):1644‐1650. Accessed 06/01/2020.
[vii] Hyassat, D., et.al. Prevalence and risk factors of osteoporosis among Jordanian postmenopausal women attending the National Center for Diabetes, Endocrinology and Genetics in Jordan. BioRes Open Access. 2017; 6(1): 85–93. Free access available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515108. Accessed 06/01/2020.
[viii] Tran T., et. al. Persistence of excess mortality following individual nonhip fractures: a relative survival analysis. J Clinical Endo Metabolism. 2018 Sep; 103(9): 3205–3214. Free access available at: https://academic.oup.com/jcem/article/103/9/3Bone 205/4996518. Accessed 05/21/2020.
Chad Deal, M.D.
Chad Deal, MD, is the head of the Center for Osteoporosis and Metabolic Bone Disease at The Cleveland Clinic in Ohio. A practicing rheumatologist at The Cleveland Clinic, he is a board certified in rheumatology and internal medicine. Dr. Deal did his undergraduate work at Washington University in St. Louis. He attended medical school at the University of Arkansas, was inducted into Alpha Omega Alpha, and graduated in 1977. His internship and residency were at Boston City Hospital in Massachusetts. He completed a fellowship in arthritis and connective tissue diseases at Boston University School of Medicine in 1982.
Dr. Deal has been in Cleveland since 1984. He was an associate professor of medicine at the Case Western Reserve University School of Medicine until 1999 when he left to join The Cleveland Clinic.
He has been an active investigator in multiple clinical trials relating to arthritis and osteoporosis and is author of more than 30 publications. He serves as a member of the Professional Meetings and Training and Workforce Committees for the American College of Rheumatology