We will now focus on patient education and adherence. An important piece of making sure that patients will properly take and receive medications to help prevent future fractures is getting them to buy into what we are discussing with them. Just like any medical choice or advice, it is crucial that the patient understands the details of their diagnosis and why a treatment plan is not only recommended but important to adhere to. Physicians or providers should foster shared decision-making with their patients to increase patient understanding and comfort, taking the time to go through with them what their diagnosis means. Also, we want to assess the social determinants of health to better guide patients to the most appropriate resources. And this will be different for each person's circumstances. Now, unfortunately, patients often either choose not to start a medication or stop taking one prematurely, putting them at increased risk for fractures. So we want to work through this with them to see what are the potential barriers and how can we help offer solutions. So some examples could be, could call the pharmacy to verify the prescription was actually received and run the prescription and determine out-of-pocket cost. This is particularly important if any medications will go through prior authorization, if they are given as injectables, either from a specialty pharmacy or at a facility. We can print out copay cards for patients with commercial insurances for medications that are picked up at pharmacies. And also to explain medication dosing and follow frequency to answer any questions that the patient may have. Especially a lot of times with injections, there are resources online from pharmaceutical companies to assist with this. Nurses can be valuable resources. Anything we can do to help the patients to ensure that they will take the medication properly and regularly will help prevent future fractures. Thinking about adherence to medication. Medications are such an important part of osteoporosis treatment, particularly in patients with a high risk for fracture. One of the biggest problems with osteoporosis is a person cannot feel it until a fracture happens. So as there is no pain involved, patients may forget to take their medications or believe it is not necessary as they are not recognizing a benefit on a daily basis. There are two common obstacles with medication. The first one is initiation. Having the patient agree to start a medication in the first place is a big hurdle to overcome, particularly as there is a lot of misinformation out there in the community and on the internet about very rare side effects. The next obstacle is adherence. For the patient to actually take the medication and understand the schedule, the dosage, and the importance of taking it as prescribed or for showing up for their appointments to receive them if there are injections involved. One way that ACE has utilized to try and present to patients and providers comparative risks is this slide here, which is shown in the back of their ACE 2020 guidelines for post-menopausal osteoporosis treatment. So as you can see here, this shows risk per 100,000 people per year. Things that we worry about, such as any fragility fracture, which is over 2,000, hip fractures over 300, and then some other things that are very important and serious, but patients may not worry about on a daily basis, such as anaphylaxis from a penicillin shot, death by motor vehicle accident, death by murder. Obviously, these numbers are very small. Then when we look at these very rare things that patients read about and become concerned that they don't want to take these medications because they could occur, such as ONJ, osteoporosis of the jaw in an osteoporotic patient, the number listed being 0.7. This is clearly very low compared to the potential risks that can occur in any given year from osteoporotic fractures. It's almost comparable to death by lightning strike in New Mexico. So to put it in this context can help patients realize the concerns for risk versus benefits with a medication and why it is so important to consider a medication treatment if necessary to prevent fractures. Another method used by ACE in the 2020 guidelines to show benefits and risks of medications and the importance of taking them is shown here in this graph. So for instance, looking at motor vehicle accidents, the concerns for injury and death can be very high. If someone wears a seatbelt, the risk of a serious injury can be decreased by 50%. But looking at injuries from the seatbelt itself is negligible as displayed in this graph. This is very similar to osteoporosis. Somebody not treated fracture risk is very high. By taking a medication such as a bisphosphonate, this reduces the risk of fracture by about 50%. And then if we look at risk from the actual medication itself that patients are concerned about, such as osteoporosis of the jaw or atypical femur fractures, again, the number is very small and negligible on this graph. It is important to recognize and address that many patients have a concern about atypical femur fractures. It is a myth that taking a medication such as a bisphosphonate introduces a high risk for atypical femur fractures. We know that these type of fractures are very rare. They are defined as stress or insufficiency fractures occurring in the femoral shaft. As shown in the picture here, it can start as a beaking or a line on the lateral aspect of the cortical bone, which then can go across and show what's called the dreaded black line, which can eventually crack. And a person could develop what they call a chalk stick fracture as shown here, where it looks like a piece of chalk that has cracked in half. Again, thankfully, this is very rare, but it is a complication that can occur in anti-resorptive medications such as bisphosphonates, denosumab, or romazosumab. This type of fracture accounts for about 1% of all femoral fractures. So a very low number compared to the typical fragility femur fractures that we see related to osteoporosis. The ASBMR reports an instance of atypical femur fractures ranging from 50 to 130 cases per 100,000 patient years. So again, very rare. And it is important to know and to let patients know that atypical femur fractures can occur in the absence of osteoporosis treatments. So it is not a cut and dry association. And there are different risk factors a person may have that could put them in a higher risk category for an atypical femur fracture. Some things that have been mentioned in the medical literature include age and race, difference in lower limb geometry, perhaps a low vitamin D level, use of other medications such as glucocorticoids or proton pump inhibitors. There are different speculated reasons why atypical femur fractures can occur outside of anti-resorptive medication use. It is something we think about. However, it is very rare, but we tell people that are on long-term medications that are anti-resorptive in nature that if they have any type of pain in the mid-thigh region, which could suggest a prodromal syndrome, to let their provider know. Another concern that comes up often when we talk to patients about considering a medication to help prevent osteoporotic fractures is the concern for osteonecrosis of the jaw. It is a myth that it is unsafe to have dental procedures or cleanings performed while on bisphosphonates. The term MRONJ or medication-related osteonecrosis of the jaw is a rare complication that can affect the jawbone. As seen in the name here, medication-related, while it can pertain to medications used to treat osteoporosis, there are other medications used in different fields that may put people at risk for this rare disorder also. It is very safe to have standard dental cleanings performed while on these medications, and we encourage our patients to have regular dental exams. It is also safe to perform non-invasive dental procedures such as fillings, scalings, root planning, root canals, and even implants. And during these procedures, osteoporotic medications do not need to be stopped. Medication-related osteonecrosis of jaw has not been associated with oral raloxifene. This is a weaker anti-resorptive medication. It has also not been associated with medications such as teriparatide and abaloparatide, which are purely anabolic. So therefore, there is no recommendation for a person on any of these medications to have to worry about osteonecrosis of the jaw. Many times, patients will clump all of these medications together, thinking that there are involved risks, and sometimes different dentists and oral surgeons may do that also, so it is important to give the proper information. Now, it is true that there are rare associations of medication-related osteonecrosis of the jaw being associated with the following medications such as oral RIV bisphosphonates, denosumab, and romazosumab. Many times when we see osteonecrosis of the jaw happen, it tends to occur more often with medications being given at higher doses more frequently, such as the bisphosphonates or denosumab, particularly in situations when a person's being treated for cancer. In a patient who has high risk for fracture, the benefit of an approximate 40 to 70% reduction in regular fragility fractures, this far outweighs the rare one in 10,000 to one in 100,000 risk of medication-related osteonecrosis of the jaw. You can't even almost make the comparison of risk versus benefits here. A tooth extraction or invasive jaw surgery may impart additional risk for medication-related osteonecrosis of the jaw, especially if there is periodontal disease or chronic infection, so we do encourage our patients to have regular discussions with their dentists or oral surgeons about these medications and to keep in contact with us as well. However, it is not recommended to interrupt osteoporosis treatment for dental procedures in patients with high risk for fracture, particularly if a person is on the medication denosumab, where we know if that medication is stopped abruptly, the person could be at high risk for fracture. This is really not recommended. Other ways that ACE has tried to relay this information to patients in terms of the benefits of taking medications to help prevent osteoporotic fractures are such as displayed here in this graph. This is also located in the back of the ACE 2020 guidelines for postmenopausal osteoporosis. So you can see here 10-year risk of fracture without treatment. The risk is about 40%, so you can see that four of these persons that are colored in as opposed to out of 10. Next to 10-year risk of fracture with treatment, that that risk is cut in half. So this is another visual way to show this. And again, you could access this at the back of the 2020 guidelines. Here is another graph located at the back of the ACE 2020 guidelines to share with patients to try and explain risks versus benefits. So the first area here shows a 75-year-old Caucasian woman with a femoral neck T-score of minus three. What is their risk for fracture if they're untreated? So about 20%, so shown with the two sad faces here. However, the next group, if that person's treated, that risk is cut in half down to 10%, so only one sad face. Whereas if we look at the last group in terms of rare disorders such as osteoporosis of the jaw, where the percentage is about 0.07%, it does not even register on here where we would have to make a determination on one of the smiley faces. So it's nice that ACE has given us different ways to share this information with patients in a more visual manner. So to summarize with some key takeaway points about osteoporosis. Unfortunately, osteoporosis has become a problem of epidemic proportions that impacts both men and women. I think it is well-recognized that women are at risk for osteoporosis getting older, but many times men are neglected. And we really, as has been said at multiple society meetings are at a crisis in the field of osteoporosis where we have many medications that are helpful. In fact, the most that we've ever had, however, patients choose not to take them because of concerns over very rare side effects. It is important to proactively screen all women starting at age 65 and all men starting at age 70. Unfortunately, again, many of our guidelines do not include men and they are missed in screening. Screening should start sooner in patients who have other risk factors and they can start at age 50 or whenever is determined to be appropriate for that particular individual. Men and women are both at risk for developing osteoporosis. Guideline-based treatment using safe, effective osteoporosis medications and lifestyle modifications can reduce the risk for fractures. This is well-established. The risk of very rare things such as atypical femur fractures and medication-related osteoporosis of the jaw is very low. And the benefits of taking medications for high-risk patients far outweigh these small risks. It is very important to have ongoing patient communication and disease monitoring for best outcomes for our patients.

osteoporosis

medication adherence

patient education

fracture prevention

shared decision-making