Hello everyone and this is Dr. Abhishek Srivastava. I am an endocrinologist from India and it gives me immense pleasure and honor to have been involved in this very short and comprehensive course on osteoporosis primarily for primary care physicians by American Association of Clinical Endocrinology. Why it was thought of? Because the World Health Organization also issued a call to action for primary care to lead on managing non-communicable diseases which involves osteoporosis also. Although osteoporosis is common but it remains under diagnosed and undertreated and primary care practitioners are critical in identifying individuals at risk for osteoporosis and osteoporotic fracture. However, recent advancement in assessment diagnosis and treatment of osteoporosis have not been incorporated into clinical practice in primary care due to numerous reasons which includes time constraints, insufficient knowledge about the session, doubts about the effectiveness of the treatment and more importantly the fear of adverse events of the drugs. And primarily to close this gap in clinical practice, we actually believe that primary care practitioners need a practical strategy to facilitate osteoporosis assessment and management and that is actually very easy to implement and that is the prime reason why the short accredited course has been thought of. To disclose, this activity is being supported by an educational grant from MGR and we are highly thankful and obliged. Here are the faculty and planner disclosures. All the faculty and office bearers have been listed here. All of the relevant financial relationships listed for these individuals have been mitigated. The objectives of this short session course would be to discuss the epidemiology, healthcare costs and disease burden related to osteoporosis, review the recent guidelines for screening, apply the latest clinical practice guidelines to develop individualized osteoporosis management plans, enhance monitoring and follow-up practices to assess treatment efficacy and improve patient progresses and then lastly address the barriers to the treatment at the level of primary care physicians. As the American population ages, osteoporosis as a non-communicable disease has become a problem of epidemic proportions and despite its serious consequences, because of unawareness, the disease is commonly under diagnosed and untreated even after a fracture occurs. Women and men are both at risk of developing osteoporosis but women are at a higher risk as compared to men and proactively screening patients at key life milestones and potentially sooner if they have certain risk factors associated contributes hugely to a timely and correct diagnosis and correct management. And more importantly, guideline-based treatment using safe, effective osteoporosis medications and lifestyle modifications can reduce the risk of fractures certainly. On a broader prospect, osteoporosis has become a growing global concern also and from 1990 to 2019, the deaths and disability-adjusted life years associated with low bone mineral density increased by almost 111 percent and 93.82 percent respectively. Globally, one in three women and one in five men aged 50 years and above will suffer an osteoporotic fracture during their lifetime and if we take the corresponding rates in the United States, it is one in two women and one in four men and that is something very seriously to be thought of and the countries with the highest disease burden of disability-adjusted life years from low bone mineral density related fractures are particularly India, China, United States, Japan and Germany. So to start with, let us begin with the guideline-based screening and diagnosing of osteoporosis. The first and the foremost thing to start with the screening and diagnosis of osteoporosis is to know the risk factors for osteoporosis and here are the lists. Post-menopausal women, being of white or Asian descent, family history of osteoporosis, low body weight, low levels of sex hormones, low estrogen in women and low testosterone in men, hyperthyroidism, lifestyle factors like smoking and alcohol intake, chronic use of certain medications like steroids, anti-convulsants, aromatase inhibitors, chronic liver disease and lastly malabsorption syndromes. Here is an interesting case to present with so that later in the slides we can correlate her values with the actual guideline-based values. So a 65-year-old Caucasian woman presents for bone density interpretation after a yearly physical examination. No history of fractures but her mother had a hip fracture in her 80s. No risk factors for osteoporosis for this woman. No risk factors for osteoporosis for this woman other than age and menopause. If we talk about the bone density, she has a low bone mass at the hip and spine, predominantly T-score of minus 2.0 at the spine and 2.2 at the femoral neck. Z-scores are normal. So how do we evaluate her further and then manage? To define osteoporosis in simplest of the forms, basically osteoporosis is a chronic condition associated with aging in which bones become porous and weak and are more likely to break, that is fracture. So there is an increased risk of fracture even with minimal trauma such as creeping or even falling from the standing height. A broken bone density actually is a serious condition that not only affects daily activities but can also lead to reduced quality of life. More importantly, need for caregiver support, work loss, hospital and rehabilitation costs, nursing home costs and increased mortality. Although osteoporosis is common but it is often undiagnosed or untreated at primary care level, leaving many people at risk for experiencing broken bones. WHO or World Health Organization has also given the criteria for the definition of osteoporosis and mainly it is based on BMD measurement, that is bone mineral density measurement performed by dual energy x-ray absorptiometry that is known as DEXA scan to determine the degree of bone loss. DEXA scan mainly provides a t-score that compares an individual's bone mineral density with the mean value for young normal individuals and expresses the difference as a standard deviation score. So normal category, the t-score defines as less than minus 1.0 and above. Low bone mass or more precisely osteopenia, t-score varies between minus 1.0 to minus 2.5 and then finally osteoporosis where the t-score is minus 2.5 and below. But before doing a DEXA scan or a bone density test, let us find out in whom bone density test should be done or could be done. So according to AAAS and NOF, women aged 65 years and older, men aged 70 years and older, post-menopausal women and men ages 50 to 69 with clinical risk factors associated, adults who have a fracture after age of 50, adults with a condition like rheumatoid arthritis or taking a medication like glucocorticoids associated with low bone mass or bone loss. In addition to WHO bone mineral density criteria, following may also be used to diagnose osteoporosis like low trauma, spine or hip fracture regardless of bone mineral density, osteopenia where t-score varies between minus 1 and minus 2.5 with a fragility fracture of proximal humerus, pelvis or distal forearm, osteopenia and high tenure fracture probability by use of FRAX that is fracture risk assessment tool based on country-specific thresholds. And what is FRAX, we will discuss in the next subsequent slides. In addition to this, primary care physicians should also try to identify patients suspected of having osteoporotic fractures. This includes routinely asking patients if they have experienced prolonged or unusual back pain which may signal osteoporotic fracture. Primary care physicians should also ask patients about signs that might indicate fractures not previously clinically recognized such as loss of height by more than two centimeters or kyphosis that is progressive spinal curvature. Primary care physicians should also evaluate for factors that increase the risk of falling such as gait abnormalities, balance problems and decreased ability to perform the timed up and go test used to assess balance and gait. Till now we discussed about the screening and diagnosis of osteoporosis but there are certain subsets of patients who have signs and symptoms that actually could indicate the high risk of possible osteoporotic fracture or even if they have no history of fractures but have a high BMD-T score. So in these subsets of patients further risk assessment should be performed because see for example over 80% of the post-menopausal women have a T score of more than minus 1.5 or minus 2. This suggests that BMD is not only the factor which could contribute to the fracture risk and it has now been established also that BMD along with other clinical factors should be taken together to improve fracture prediction risk and here comes the fracture risk assessment tool. BMD is not sensitive enough to predict fractures that is the reason you do not need BMD to calculate risk. Fracture risk assessment tool which was launched in 2000 is the most widely used prediction tool to calculate the risk of fractures. It incorporates risk factors including age, sex, BMI, fracture history and others with or without BMD measurement. It is a computer-based algorithm that calculates the 10-year probability of fracture. Fracture of hip, spine, wrist or humerus and hip fracture also should be used for patients who are treatment naïve but however clinical judgment is important in determining whether or not to treat patients. As discussed fracture risk assessment tool assesses 10-year probability of hip fracture and major osteoporotic fracture. In the recent 2020 updated double ACE or ACE guidelines provide criteria for categorizing patients into high risk and very high risk for fracture using the FRAX assessment tool. Occurrence and recency of a prior fracture are actually critical in determining patients risk for future fracture. In the US, patients are placed into the high risk category for fracture if a woman is menopausal or have experienced a prior fracture or have a T-score of less than 2.5 together with a FRAX probability of more than 20% for major osteoporotic fracture or more than 3% for hip fracture should be considered for treatment. Remember the case we presented at the beginning. So let us see how we can predict the future fracture risk using the fracture risk assessment tool along with the BMD. So 67-year-old Caucasian women with no history of fractures, T-score at the hip is minus 2.2. Her mother sustained a hip fracture in her 80s. So taking into consideration these parameters along with proper history, we can clearly see that the 10-year probability of fracture in percentage for this woman was 21% for major osteoporotic fracture and 3.1% for hip fracture. So this clearly indicates that this woman needs treatment. That is how fracture risk assessment tool is beneficial in predicting the future fracture risk.

osteoporosis management

primary care education

Fracture Risk Assessment Tool

endocrinology course

non-communicable disease