CHICAGO — Endocrinologists are “behind the curve” when it comes to treating osteoporosis, Dr. Nelson B. Watts said at the annual meeting of the American Association of Clinical Endocrinologists.
“There is roughly the same number of rheumatologists as endocrinologists in the United States,” said Dr. Watts, director of the osteoporosis and bone health program at the University of Cincinnati. “In academic centers, endocrinologists are often the 'boneheads,' but in clinical practice, rheumatologists compared with endocrinologists are twice as fast as we are in taking up ownership of densitometry or prescribing osteoporosis drugs.”
Osteoporosis groups are “in pretty good agreement” on several of the guidelines for treatment of the disorder, according to Dr. Watts, who consults for and receives grants from a number of pharmaceutical companies. “The National Osteoporosis Foundation, AACE, and the North American Menopause Society are all in agreement that patients with T scores of −1.5 or above are rarely candidates for pharmacologic treatment,” he said. “And they all agree that those with T scores of −2.5 or below should be treated even in the absence of risk factors. It's that zone in between where there's disagreement.”
The National Osteoporosis Foundation says that if the patient has risk factors for osteoporosis—such as previous fractures and advanced age—and her T score is between −1.5 and −2, the physician should go ahead and treat the patient. The doctor also should treat the patient if the T score is −2 or below, even in the absence of risk factors, the foundation says. AACE suggests treating patients whose T scores are between −1.5 and −2.5 only if risk factors are present, while the North American Menopause Society advocates no treatment if the T score is between −1.5 and −2 but suggests that patients between −2 and −2.5 should be treated if risk factors are present, Dr. Watts said.
How should physicians handle this “gray zone”? The problem with treating only patients with T scores of −2.5 or below “is that there are patients above −2.5 who actually have a fairly high 10-year probability of fracture, and unless we're smart enough to know by intuition what the right risk factors are, many of those patients aren't being treated,” said Dr. Watts.
The most recent thinking is toward moving away from T scores to something called “absolute fracture risk” or “absolute fracture probability,” he continued. “This will consider bone density, but in countries that have little or no access to bone density [measurement], this will be based solely on clinical risk factors.” In addition to age and history of fractures, other risk factors that are likely to be included are corticosteroid use, cigarette smoking, alcohol use, and rheumatoid arthritis. Also, patients who self-rate their health as poor or fair are almost twice as likely to fracture as are those who say their health is good or excellent.
Dr. Watts offered these tips on managing patients with a high fracture risk:
▸ Consider hip protectors and assistive devices. There are conflicting data on whether using hip protectors reduces the risk of fracture. But physicians who are interested in recommending them can easily find them on the Internet.
▸ Be judicious with pharmacologic therapy. Dr. Watts said bone drugs such as alendronate, raloxifene, ibandronate, risedronate, and calcitonin are only shown to reduce the risk of fracture in patients with low bone density, and are not appropriate if the risk is due to poor eyesight, poor hearing, poor balance, and muscle weakness.
▸ Advocate exercise. “Weight-bearing exercise is important,” he said. “I recommend patients walk for 30–40 minutes a session, 3–4 sessions per week.”
▸ Remember that when it comes to calcium, more is not always better. The optimal calcium intake is 1,200 mg per day for adults aged 50 and older, he noted. The average adult gets only half of what is needed from the diet, so most people do need a supplement; 700–1,000 mg per day should be adequate. But many people take too much. “I see patients who are taking in 3,000–3,500 mg of calcium per day. So I spend a fair amount of time telling patients to take less calcium by way of supplements, rather than more.”
▸ Consider recommending vitamin D. “An adequate 25-hydroxyvitamin D level is 30 ng/mL or more,” he said. “Many patients require 1,000–2,000 IU of vitamin D per day to achieve this level.”