Author

Marla Shapiro

C.M, MDCM, CCFP, MHSc, FRCPC, FCFP, NCMP
Professor, DFCM, University of Toronto
Toronto, ON

Reviewer

Christine Palmay

MD, CCFP, FCFP
Midtown Health & Wellness Clinic
Toronto, ON

Osteoporosis is a disorder of the bone. In it there is bone loss that ultimately damages the skeletal architecture leading to weakness of the bones which predisposes patients to fracture. Many are surprised to know that this is not a curable disease, but a chronic disease and as such will require prolonged management. As a result, it is critical for us to identify those at risk and develop long term treatment strategies.

The objectives of management are to reduce the risk of fracture by promoting bone health. In addition, osteoporosis medications are used to increase both bone strength and Bone Mineral Density (BMD). Most importantly, we must engage patients in understanding their role in chronic disease management.

Watch this video summary with blog author Dr. Marla Shapiro

How do we identify patients at high and very high risk of fracture?  Why is that important?

As always, we start with a complete history. It is ESSENTIAL to proactively ask about prior fractures, as patients are often unaware of the significance of their fracture and often dismiss the event as a  natural consequence of a fall. I remind patients that in general, healthy bones don’t break whereas brittle bones do.

Fracture risk can be assessed by several tools. I often use FRAX. (International Osteoporosis Foundation https://www.osteoporosis.foundation/health-professionals/diagnosis). While no tool is perfect, we can identify patients at high risk and very high risk of fractures. I also recommend sharing this process with patients so that they understand that we are not only treating a BMD score in isolation, but we are treating their risk of fracture and subsequent preventable outcomes: morbidity such as pain, a loss of independence and potential mortality.

Once we have identified an at-risk patient, we want to maintain skeletal mass and prevent age-related bone loss. It is critical to prevent falls which are a significant risk factor for fracture.

By using FRAX we can identify high-risk and very high risk patients. By plugging in our patient specific information, we will get two scores. One is the MOF risk which is the risk for major osteoporotic fracture inclusive of sites such as hip, spine, wrist, or humerus. A score of 20 % or greater puts the patient at high risk of fracture. A score greater than 30% puts them at very high risk and will often include patients who have had a fracture in the last year or has a history of multiple fractures. The second score this tool provides is the risk of hip fracture. A score of 3% or greater at the hip site means the patient is considered high risk and a risk of hip fracture score of greater than 4.5% means this is a very high-risk patient for future fracture.

What are the implications of osteoporosis and fractures?

So, what about treatment?

We have multiple guidelines that can help to differentiate therapies. Societies such as the SOGC, NAMS, AACE and the Endocrine Society all agree that bisphosphonates and denosumab can be used as a first line for these high-risk patients. The SOGC as well endorses the use of teriperatide or romosozumab. Some of these international organizations acknowledge looking at head-to-head studies and would prefer denosumab over bisphosphonate for a high-risk population.

What about atypical fractures