important menopause information
Two weeks ago I spent two days at the NIH at at a conference on osteoporosis: Pathways to Prevention: Appropriate Use of Drug Therapies to Prevent Osteoporotic Fractures. The goal of the meeting was to bring forward experts and the data to consolidate information regarding recommendations for treatments, understanding risks and side effects of medications, and to better understand gaps in our knowledge. This will hopefully lead to additional research to fill in these gaps.
Because this topic is so broad, I will break it down into smaller topics, and report the information as a series. Let’s start with the burden of the disease, a lecture given by Dr. Elizabeth Shanes.
Osteoporosis is a very significant public health burden. Approximately 10 million Americans have osteoporosis, but most of them do not know it. Osteoporosis is defined as weakness of the bones, resulting in increased risk of fractures. Fractures can lead to surgery, disability, immobility, loss of independence, and decreased life span. As we age, most adults want to maintain their independence and quality of life.
Here are some facts that we know for sure:
There are 1.5-2 million osteoporotic fractures per year in the US, mostly involving the spine, hip, wrist, and pelvis. Women will incur 70% of the burden of these fractures. 50% of women over the age of 50 will sustain at least one fracture in their remaining years. Caucasian women carry the highest risk.
The cause is low bone density which can be measured and monitored. The risk of osteoporosis increases with age. About 44% of women over age 50 have low bone mass. The risk of osteoporosis over age 50 is at least 10%, and may be as much as 30%.
Low bone density predicts fractures, both traumatic fractures as well as low-trauma fractures.As bone density decreases, the risk of fractures increases.
Once you break a bone, you are more likely to break more. If your break a vertebrae, you are 5 times more likely to break another vertebra, and 3 times more likely to break your hip. If you break one vertebrae, you have a 25% chance of breaking another within one year.
Adults who break bones have significant increased morbidity and mortality. After a broken hip, your risk of death in the next three months increases 5-8 times, and the increased mortality remains for the next 10 years. Studies show that other fractures including vertebral, femoral, tibial, multiple rib and other fractures are all associated with increases in mortality. About 25% of women who fracture a hip will live less than a year.
Fractures also decrease mobility. 50% of adults who break a hip will have difficulty walking one year later. Vertebral fractures are related to back pain and difficulty with managing tasks of daily living. Studies show that quality of life decreases after fractures, and the more fractures, the more rapid is the decline. Many people who fracture never regain their quality of life.
The cost to the healthcare system and individuals is dramatic. In 2005 there were 2 million fractures at a cost of 2 billion dollars. One hip fracture costs about $30,000 to treat. As the population ages, the healthcare costs related to fractures will increase. Those who are insured that fracture have twice as high health care costs as those who do not.
Fractures are preventable. All women should be encouraged to take adequate doses of calcium and Vitamin D, and exercise to improve muscle strength and balance. Fall prevention strategies should be discussed with patients. The biggest cause of falls is lack of muscle strength as we age.
Once osteoporosis has been diagnosed, medication is necessary to treat the disease. Many patients will be motivated to increase their calcium, Vitamin D and exercise at that point, but significant improvement in fracture risk is difficult to achieve. Short term use of certain FDA approved medications have been proven to prevent fractures. The long term strategies for drug use need further study.
Medications that prevent fractures are not being effectively. Bisphosphonates (Fosamax, Actonel, Boniva and Reclast) for osteoporosis treatment were approved in the mid-1990’s. Their use increased until about 2008 when media reports surfaced about side effects. The use of these drugs have sharply declined since then, although the risk are very, very rare. The perception by many patients is that the drugs do not work or make the bone more brittle, and the side effects are frequent. This is not true.
Since these reports, physicians have focused on treating those most at risk of fractures, rather than using the drugs preventatively, and have begun using drug holidays when appropriate.
Data indicates that even after hip fractures, less women are being treated for their osteoporosis. Less than 20% of women who break a hip are started on medication to prevent another fracture. New data tells us that for the ten years from 2005-2015, hip fracture rates were decreasing, then stabilized, and are now increasing. There have been about 11,000 more hip fractures and 2300 deaths attributed to the change in the trend. Medicare has markedly lowered reimbursement to doctors for osteoporosis testing in the office, so many practitioners no longer offer this service. The trend in decreased testing and concern of patients over side effects of medication, both contribute to the increase in fractures.
Physicians need to understand the concerns of patients about side effects, and understand the barriers to initiating and continuing treatment, including cost and insurance restrictions. Physicians also need to effectively communicate with patients the devastating effect of fractures, and learn how to prevent and diagnose complications sooner than later.
Here are Dr. Shanes final comments: “Osteoporotic fractures are common, costly, debilitating, disabling, and deadly. Although we have drugs to prevent them, those drugs are not being used.”
We have an opportunity to do better.
The next article in the series will look at who is at risk for a fracture, and who should be screened. We will also talk about how to interpret your results. Stay tuned.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
NIH: Pathways to Prevention: Osteoporosis
Elizabeth Shane, MD. Osteoporosis Fracture Prevention in the US, October 30, 2018