QuickConsultCAST—Leading Experts Respond
to Frequently Asked Questions (FAQs) About Osteoporosis

Disclosure of Commercial Support: The following questions were posed in oral or written form by physicians participating in a live symposium series titled, Screen and Intervene: Critical Challenges in Osteoporosis—Year 2006 Update. The symposium was supported by an independent educational grant from Roche Laboratories Inc.

The following questions were answered by E. Michael Lewiecki, MD, FACP, Osteoporosis Director, New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico, under the auspices of his involvement as a faculty member for the Critical Challenges in Osteoporosis—Year 2006 Update symposium series.

Faculty Responder Disclosure Statement. Dr. Lewiecki discloses that he has received Grant/ Research Support from Merck, Eli Lilly, Novartis, sanofi-aventis, Amgen, Pfizer, Wyeth-Ayerst, Roche, GlaxoSmithKline, Procter & Gamble, NPS; has participated as a consultant, in advisory boards, on th eSpeakers’ Bureau, or at sponsored speaking events on behalf of Merck, Eli Lilly, Novartis, sanofi-aventis, Amgen, Wyeth-Ayerst, Roche, GlaxoSmithKline, Procter & Gamble, Servier, NPS, and is a stockholder in GE and Procter & Gamble.

Questions and Answers:

Estrogen Discontinuation—
Therapeutic Options

Question 1:  If a 55-year old woman had been on estrogen replacement therapy for 5 years for postmenopausal symptoms, and then came to her physician because she wanted to discontinue her estrogen what criteria would you use to initiate bisphosphonate therapy? How would her BMD affect your decision to initiate bisphosphonate therapy and/or recommend discontinuation of estrogen? Under what circumstances would you recommend switching from estrogen to raloxifene? If you started the patient on raloxifene, would you also add a bisphosphonate?

QuickCONSULT: Discontinuation of estrogen therapy (ET) may be associated with rapid bone loss. The decision to start bisphosphonate therapy or any pharmacological therapy should be based on estimated fracture risk. Low BMD as well as clinical risk factors for fracture (such as age, personal history of fracture, family history of fracture, smoking, long term glucocorticoid use, etc.) should be considered. The NOF (National Osteoporosis Foundation) recommends pharmacological therapy if the T-score is less than -2.0 or if the T-score is between -1.5 and -2.0 and risk factors are present. Raloxifene would be a good choice if there is a high risk of breast cancer and skeletal benefit is desired. There is no proven additive benefit in terms of additional fracture risk reduction by combining two drugs.

Nondiagnostic DXA—Approach

Question 2: In a patient in whom osteopenia/osteoporosis is suspected, but DXA shows nondiagnostic T scores, do you recommend x-ray (lateral view) of thoracic/lumber spine to evaluate for occult compression fractures? Should this be routine? What clinical or BMD measurements would prompt a vertebral x-ray?

QuickCONSULT: VFA (vertebral fracture assessment) by DXA or spine x-ray should be considered if the results are likely to influence therapy. Spine imaging is not necessary for all patients. The NOF recommends drug therapy for patients if a vertebral fracture is present regardless of T-score.

Frequency of DXA Measurements

Question 3: My understanding, thus far, is that a minimum of 2 years is necessary between DXA scans for a reliable interpretation of results, i.e. monitoring effects of therapy.  However, in certain circumstances I am under the impression that more frequent BMD measurements may be helpful. Should I be checking a DXA one year after starting therapy? Two years? Are there patient or other factors which influence this decision?

QuickCONSULT: A follow-up DXA as soon as 6 months should be considered if a high rate of bone loss is suspected, such as a patient being started on high dose glucocorticoid therapy. In a patient being treated for postmenopausal osteoporosis (PO), a follow-up in 1-2 years is reasonable. I usually do the first follow-up DXA in 1 year to be sure there is no bone loss. If BMD is stable or increased and the patient is adherent to therapy, then there is probably a reduction in fracture risk. Medicare will cover a 1 year follow-up DXA in some but not all states.

Role of Lateral Chest Film

Question 4:  Since a lateral chest film can reveal compression fractures, should it routinely be ordered with the DXA?

 A lateral CXR does not visualize lumbar spine fractures, exposes the patient to greater radiation, and is usually more inconvenient than doing a VFA by DXA, which provides an image of both L- and T-spine. Where VFA is not available, then a lateral L- and T-spine x-ray may be helpful.

Screening in Women Less Than 60 Years of Age

Question 5: Should we screen women below age 60 for osteoporosis?

QuickConsult: DXA is indicated for postmenopausal women less than age 65 if risk factors for osteoporosis are present.

Cessation of Bisphosphonate and BMD Changes

Question 6: When a patient stops bisphosphonate therapy, does the BMD decrease rapidly as in the immediate postmenopausal period?

QuickCONSULT: No. There is persistence of suppression of bone turnover and BMD benefit due to the long bone half-life of bisphosphonate, but there will eventually be a slow rise in bone turnover and drop in BMD. This may occur over a period of months to years depending on the drug used, the length of treatment, and patient factors.

T-scores in Men

Question 7: How do you apply the T-score to a man?

T-scores should be used, and the WHO diagnostic criteria applied to men age 50 and older. In younger men, Z-scores, not T-scores are advised, and the WHO criteria should not be applied.

BMD vs T-scores

Question 8: What do you mean by always compare BMD never T-scores?

QuickCONSULT: T-scores may vary if there have been changes in the mean BMD or SD of the reference database that is used, even when there is no change in BMD. Therefore, BMD in g/cm2 should always be used for comparisons.

Frequency of Serial DXA

Question 9: In a rheumatolgy practice, do you do perform serial DXA once a year and respond to changes, or do you adhere to the DXA every two years position and why?

QuickCONSULT: I do a follow-up DXA one year after starting or changing therapy, and less often thereafter if the patient is responding by having stability or an increase in BMD.

Initiating Therapy in the Elderly

Question 10: I encounter a number of women patients in their 70s and 80s who are referred to my practice with osteoporosis based on T-scores of less than -2.5. Their x-rays do not demonstrate any fractures, although the may have mild scoliosis. What is the approach to beginning prevention-oriented therapy in this age group? Should we always start therapy, regardless of age at time of recognition, if the T-scores support therapy?

QuickCONSULT. Elderly women with an osteoporotic T-score are at high risk of fracture and can benefit from drug therapy provided there are no contraindications and the patient agrees to this. Regardless of the decision about drug therapy, every effort should be made to assure adequate intake of calcium, vitamin d, weight-bearing exercise, and fall prevention.