Optimizing Bone Health to Prevent Osteoporotic Fractures: A Customized Approach

About 1 in 2 women and 1 in 5 men over 50 years old worldwide will experience an osteoporotic fracture in their lifetimes. The International Osteoporosis Foundation estimates that one of these fractures occurs every three seconds. Timely screening of bone mineral density (BMD) and treatment with antiresorptive or anabolic medications have been proven to reduce the risk of fractures. But many patients are not being adequately screened for osteoporosis, let alone treated. The metabolic bone health specialists at HSS at NewYork-Presbyterian Weill Cornell Medicine can conduct a thorough work-up of your patients and match those at risk for fractures with osteoporosis medications tailored to their needs.

Osteoporosis vs. Osteopenia

BMD is measured using dual-energy x-ray absorptiometry (DXA) testing. Osteopenia or low bone density is characterized by a BMD reduction below normal reference values (t-scores), but not low enough to meet the criteria for osteoporosis. The World Health Organization defines osteopenia as a t-score between -1 to -2.5, while values less than or equal to -2.5 define osteoporosis.

Treatment is indicated when DXA t-scores are in the osteoporotic range for the hip or spine. Additional indications include low-energy fractures with scores in the low bone density range or elevated FRAX scores, which account for other risk factors and family history.

Bone Mineral Density Screening Guidelines

Baseline DXA testing for BMD is indicated for:

• Women aged 65 years and older
• Men aged 70 and older
• Adults over 50 with a fragility/low-energy fracture, such as those affecting the humerus, forearm, hip, or spine
• Adults with a disease or condition associated with low bone mass or bone loss
• Adults taking medications associated with low bone mass or bone loss, such as steroids
• Adults with lifestyle factors that lead to bone loss, such as excessive alcohol intake
• Women during the menopausal transition and men younger than 70 with risk factors for low bone mass, including low body weight and a history of fractures
• Women who have lost more than 1.5 inches and men who have lost more than 2 inches from their tallest height

Osteoporosis Treatment

Many patients are identified for osteoporosis treatment after presenting to the Emergency Department with a low-energy fracture. The HSS at NewYork-Presbyterian Weill Cornell Medicine orthopedic team first provides acute care to stabilize the fracture. They then refer the patient to the metabolic bone team, which is integrated into the department, for an assessment that includes DXA to evaluate BMD and lab work to assess bone health. The team optimizes the patient’s bone health and discusses treatment to prevent secondary fractures. Patients receive guidance about how to enhance calcium and vitamin D intake through diet and how to prevent falls. They may be prescribed an osteoporosis medication such as:

• Antiresorptive drugs which prevent bone loss and reduce fracture incidence
• Anabolic drugs, which build new bone and reduce fracture incidence

Doctors match patients with the therapies that are most likely to be effective and promote compliance, taking into account age, medical history/comorbidities, overall health, and test results.

Antiresorptive Agents

• Alendronate (Fosamax®, Fosamax® Plus D)
• Risedronate (Actonel®, Actonel® with Calcium, and Atelvia®)
• Ibandronate (Boniva®)
• Zoledronic acid (Reclast®)
• Denosumab (Prolia®)
• Raloxifene (Evista®)

These drugs may be pills taken weekly or monthly or intravenous infusions administered biannually or annually.

Anabolic Drugs

• Teriparatide (Forteo®) daily self-injection
• Abaloparatide (Tymlos®) daily self-injection
• Romosozumab (Evenity®), two subcutaneous injections given once monthly during an office visit

Treatment Side Effects

Drug holidays are used for patients on bisphosphonates to limit side effects and complications. Long-term use of bisphosphonates, for example, has been associated with an increased risk of atypical femoral fractures, which is why physicians often recommend a drug holiday for patients taking these medications. The risk of associated side effects is very low compared to the risk of fracture. In 10,000 women receiving IV bisphosphonate therapy for three years, the medication prevented 149 hip fractures and 541 clinical fractures and caused two atypical femur fractures, demonstrating its benefits for fracture prevention.

Other low-risk associated side effects include osteonecrosis of the jaw (ONJ). In a patient at high risk of fracture, the approximate 40%-70% reduction in fracture risk far outweighs the rare 1/10,000 to 1/100,000 risk of medication-related ONJ. In the FREEDOM extension trial of denosumab, the real-world incidence of ONJ in osteoporosis patients treated for up to 10 years was 5.2 cases per 10,000 subject years.

Osteoporosis medications can also be prescribed to promote healing in patients scheduled to have orthopedic surgeries, such as spinal fusion or joint replacement. The drugs not only treat underlying osteoporosis but have been studied to improve fusion rates in patients undergoing spinal fusion and to speed healing time for people with fractures.

The Benefits of Treatment

Regardless of the chosen osteoporosis agent, all patients on these medications have a lower risk of fractures than those with low BMD who are not treated. That has important implications, since the mortality rate among patients sustaining hip fractures can be as high as 20%-40% during the first year after the injury. Post–hip fracture usage of bisphosphonates and denosumab is associated with lower mortality risks compared with no anti-osteoporosis treatment. In one study, patients taking anti-osteoporosis medications after a hip fracture had a 31% reduction in overall mortality risk.

Referring a Patient

Have your eligible patients been screened for osteoporosis? Contact us at 212-746-4500 to refer a patient to HSS at NYP Weill Cornell Medicine. Our metabolic bone health specialists are also experts in the care of rare diseases such as Paget's disease, hypophosphatemic rickets, osteogenesis imperfecta, and other bone dysplasias.