Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.
Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.
click for large version
click for large version
Management
Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.
In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.
Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.
Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8
Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7
Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9