Osteoporosis Screening and Management in Primary Care

Introduction

This executive summary outlines the key recommendations and insights presented during a CommonSpirit Health grand rounds on September 20th, focusing on the recently published system-wide guidelines for the screening, diagnosis, and medical management of osteoporosis. The initiative, driven by the need to standardize care across primary care and specialist settings, incorporated updated guidance from major professional societies. The grand rounds featured presentations by Dr. Kavita Chawla, a general internist passionate about evidence-based medicine, and Dr. Brian Jiang, an endocrinologist specializing in metabolic bone diseases, with contributions from Anne Wright, System Director of Advanced Practice Ambulatory Care Operations. The primary objectives were to emphasize the impact of osteoporosis, define diagnostic criteria, identify individuals for screening, detail treatment and monitoring strategies, and clarify when referral to a specialist is necessary.

The Burden and Importance of Osteoporosis

Osteoporosis represents a significant illness burden, with an estimated 2 million fractures annually in the US. Alarmingly, nearly 80% of older Americans who suffer fractures are not tested or treated for osteoporosis. The incidence is particularly high in women, with one in two post-menopausal women expected to sustain an osteoporotic fracture in their lifetime, exceeding the combined incidence of myocardial infarction, breast cancer, and stroke. Men are also at risk, with up to one in four men over 50 experiencing such a fracture. Beyond the human cost, osteoporosis poses a substantial economic burden, with annual costs projected to reach $25 billion by 2025. At the individual level, vertebral compression fractures significantly increase the risk of subsequent vertebral fractures and are associated with chronic pain and higher mortality. Hip fractures are particularly debilitating, with one in two individuals not returning to their previous level of function, and a significantly higher likelihood of becoming wheelchair-bound compared to the general population. These compelling statistics underscore the critical need for effective screening, diagnosis, and management of osteoporosis in primary care.

Diagnosis of Osteoporosis

The Common Spirit Health guidelines define osteoporosis based on any of the following criteria:

• Bone mineral density (BMD) that is 2.5 or more standard deviations below the peak bone mass (T-score ≤ -2.5).
• A 10-year absolute fracture risk of 20% or greater as determined by the Fracture Risk Assessment Tool (FRAX).
• A history of a fragility fracture at the hip, vertebra, humerus, or pelvis, resulting from low trauma such as a fall from standing height or less. Such a fracture is itself diagnostic of osteoporosis, regardless of BMD.

Primary care clinicians are advised to check patients' height annually, as a loss of 1.5 inches or more may indicate occult vertebral fractures, which are diagnostic of osteoporosis.

Screening for Osteoporosis

DEXA (dual-energy X-ray absorptiometry) is the preferred method for screening. The axial skeleton (lumbar spine and nondominant hip, ideally both hips at baseline) should be assessed. Forearm DEXA may be indicated in specific situations.

Screening recommendations align with the USPSTF guidelines, which currently recommend:

• Routine DEXA screening for all women aged 65 and older.
• Screening for women younger than 65 who have risk factors for osteoporosis. These risk factors include but are not limited to:
  • Low body mass index (BMI < 19).
  • History of low-impact fractures.
  • Long-term insulin use (Type 1 or Type 2 diabetes).
  • Premature menopause (before age 45, surgically or otherwise).
  • Conditions associated with malabsorption, particularly Roux-en-Y gastric bypass.

The USPSTF is currently updating its recommendations, but no major deviations are expected. It was also noted that in very elderly patients where DEXA may be challenging, the FRAX score, utilizing age, sex, weight, and risk factors (and optionally BMD), can help justify treatment even without a DEXA scan. There is generally no upper age limit for considering osteoporosis screening and management, as fracture risk continues to increase with age, and intervention can significantly impact quality of life and independence.

Fundamental Principles of Bone Health and Initial Management

Regardless of pharmacological treatment, adequate calcium (1200 mg/day, prioritize dietary sources) and vitamin D (maintain serum levels between 30-50 ng/mL, typically through supplementation) are crucial for bone health. Weight-bearing exercise most days of the week, along with muscle and balance strengthening exercises two to three times a week, are also essential. Counseling on modifiable risk factors such as smoking cessation and limiting excessive alcohol intake (≥ 3 drinks/day) is vital. Fall risk reduction strategies, including addressing balance issues, vision, and neuropathy, should be implemented.

Pharmacological Treatment of Osteoporosis

Bisphosphonates (e.g., alendronate) are the first-line pharmacological treatment for osteoporosis in primary prevention (no prior fragility fractures or severe osteoporosis) and are typically prescribed for 5 years. While patients may express concerns about side effects like osteonecrosis of the jaw, this risk is rare, and a risk-benefit discussion with dentists is recommended.

Denosumab is another effective anti-resorptive agent, particularly useful in patients with chronic kidney disease. However, it carries a risk of hypocalcemia upon initiation in such patients and, critically, discontinuation can lead to a high risk of multiple vertebral fractures. Therefore, if denosumab is stopped, patients must be transitioned to an anti-resorptive agent, ideally a bisphosphonate. Denosumab also requires specific documentation and often prior authorization, with significant associated costs. A "drug holiday" is not applicable to denosumab.

Anabolic treatments (e.g., teriparatide, abaloparatide, romosozumab) are reserved for high-risk patients with a history of multiple vertebral fractures or hip fractures after low-impact trauma. These treatments have a limited duration (1-2 years) and must be followed by anti-resorptive therapy (ideally bisphosphonates) to maintain bone density gains. Starting an anti-resorptive agent before anabolic therapy can blunt the anabolic response, emphasizing the importance of specialist consultation before initiating these treatments. Anabolic treatments are expensive and require careful consideration of contraindications and potential side effects.

Referral to an Osteoporosis Specialist

Referral to an endocrinologist or bone specialist is recommended in several situations:

• Consideration of anabolic therapy.
• Patients on denosumab who require a drug holiday but are unable to transition to bisphosphonates (e.g., eGFR < 30).
• Patients who continue to fracture despite active osteoporosis therapy.
• Patients with very low bone density (T-score < -3) without an obvious secondary cause, warranting further investigation for underlying conditions.
• Any situation where the primary care clinician feels uncomfortable managing the patient's osteoporosis.

Monitoring Osteoporosis Treatment

Follow-up DEXA scans should generally be performed approximately every 5 years for patients on bisphosphonates or denosumab, unless there is a need to assess the response to a change in therapy or following a fracture. If a drug holiday is being considered after 5 years of bisphosphonate therapy, a DEXA scan should be performed at the start of the holiday, with subsequent scans typically every 2-3 years based on risk factors and BMD stability. For individuals not initially meeting diagnostic criteria but being monitored, repeat DEXA scans every 3-5 years may be appropriate. It is crucial to perform follow-up DEXA scans on the same machine whenever possible to ensure accurate interpretation of changes in BMD. Stability of BMD and absence of fractures are considered indicators of successful therapy, and a failure to see a significant increase in BMD does not necessarily indicate treatment failure.

Conclusion

The CommonSpirit Health guidelines provide a comprehensive framework for primary care clinicians to effectively screen, diagnose, and manage osteoporosis. Recognizing the significant burden of this condition and implementing evidence-based strategies for risk assessment, lifestyle modification, and pharmacological intervention are essential for improving patient outcomes and reducing the incidence of fragility fractures. Prioritizing fundamental bone health, understanding the nuances of different treatment options, and knowing when to involve specialist expertise are key to optimizing the care of patients with or at risk for osteoporosis. The emphasis on capturing fractures, considering FRAX scores in certain populations, and the importance of consistent DEXA scanning further enhance the guidelines' practical application in primary care settings. Continuous education and awareness, coupled with effective communication with patients and specialists, will contribute to better management of this prevalent and impactful condition.

This executive summary was generated using an AI-powered tool to enhance clarity, efficiency, and readability. While AI assisted in drafting this summary, it has been reviewed and refined to ensure accuracy and alignment with our objectives.