clinical topic updates

Osteoporosis Care: Innovations and Paths to Success

by Tom Iarocci, MD

Overview

The prevention of fragility fractures is within reach, despite challenges in the current paradigm of osteoporosis care. Among the developments expected to narrow the gap are treatment innovations, the development of new and improved decision‐making tools, disease champions, and systemic approaches involving the use of a Fracture Liaison Service (FLS).

Expert Commentary

Tom Iarocci, MD

Editor-in-Chief, Expert Perspectives in Medicine
University of Maryland School of Medicine
Baltimore, MD

“Developments in research and therapeutics may enable those who currently care for patients with osteoporosis to emerge from the present paradigm with better tools and in a more empowered stance.”

Tom Iarocci, MD

Fundamental advances in the understanding of the pathogenesis of osteoporosis drove the development of novel therapeutic approaches, including estrogen, selective estrogen receptor modulators, denosumab, teriparatide, and abaloparatide, among others. The field has also benefited from the introduction and use of bisphosphonates, which are currently an inexpensive means of inhibiting osteoclastic bone resorption. Continued therapeutic advances are expected, spurred by the need for treatments that have more potent effects on fracture risk and bone mineral density, and that help to maintain appropriate treatment targets.

Developments in research and therapeutics may enable those who currently care for patients with osteoporosis to emerge from the present paradigm with better tools and in a more empowered stance. For instance, ongoing research aims to find solutions to address patient concerns with current therapies, including the risk of rare but significant adverse events. Investigators are exploring ways to diagnose atypical femoral fractures before they occur. Ongoing research also aims to find methods of helping clinicians to identify patients who may be at an increased risk of this rare complication, even before osteoporosis treatment is initiated. The development of improved decision‐making tools is also anticipated; for instance, improved tools are expected to help guide decisions regarding ordering follow‐up studies, such as femur x‐rays or extended femur dual‐energy x‐ray absorptiometry, particularly for patients who have been on therapy for more than 3 to 5 years.

“FLS care significantly reduces post-fracture mortality, especially in patients with hip fractures. Further, FLS implementation is cost-effective compared with usual care.”

Tom Iarocci, MD

Numerous approaches may be needed to curb the looming epidemic of fragility fractures. Increasingly, the gap in osteoporosis diagnosis and treatment is recognized as a systemic problem that may be particularly amenable to a more systemic solution. Population-based screening has been shown to be effective in reducing osteoporotic fractures, especially hip fractures. Moreover, osteoporosis has been identified as a disease in need of a champion, and related resources have therefore been developed.

An FLS focuses on preventing fractures by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. The Own the Bone program, for example, provides a simple, easy-to-use tool to enable the establishment of an FLS in a variety of health care settings, including hospitals and practices in the community. FLS implementation reduces the risk of subsequent fracture in patients with incident vertebral or hip fractures. FLS care significantly reduces post-fracture mortality, especially in patients with hip fractures. Further, FLS implementation is cost-effective compared with usual care. The Own the Bone website also offers links to numerous resources and tools to advance the cause of osteoporotic fracture prevention, including remote training services, program partnerships, symposia, webcasts, and a calendar of annual events.

Today, health care providers struggle to treat numerous diseases that are presently intractable, such as Alzheimer’s disease and many different types of cancer. In contrast, the prevention of fragility fractures is clearly within reach even now, despite all of the challenges associated with osteoporosis care, and preventive efforts may become more efficient with expected innovations and advances.

References

American Orthopaedic Association. Own the Bone website. https://www.ownthebone.org. Accessed February 13, 2020.

Briot K. Fracture liaison services. Curr Opin Rheumatol. 2017;29(4):416-421.

Conley RB, Adib G, Adler RA, et al. Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition. J Bone Miner Res. 2020;35(1):36-52.

Fontalis A, Kenanidis E, Kotronias RA, et al. Current and emerging osteoporosis pharmacotherapy for women: state of the art therapies for preventing bone loss. Expert Opin Pharmacother. 2019;20(9):1123-1134.

Gupta MJ, Shah S, Peterson S, Baim S. Rush Fracture Liaison Service for capturing “missed opportunities” to treat osteoporosis in patients with fragility fractures. Osteoporos Int. 2018;29(8):1861-1874.

Khosla S, Cauley JA, Compston J, et al. Addressing the crisis in the treatment of osteoporosis: a path forward. J Bone Miner Res. 2017;32(3):424-430.

Nakayama A, Major G, Holliday E, Attia J, Bogduk N. Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int. 2016;27(3):873-879.

Sujic R, Beaton DE, Mamdani M, et al; Ontario Osteoporosis Strategy Fracture Screening and Prevention Program Evaluation Team. Five-year refracture rates of a province-wide fracture liaison service. Osteoporos Int. 2019;30(8):1671-1677.

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