Call to action seeks to address ‘crisis’ in treatment of osteoporosis

Nearly 3 dozen bone health-related organizations have issued a joint “call to action” to increase the screening, diagnosis and treatment of individuals at high risk for fractures, the president of the American Society for Bone and Mineral Research announced during the organization’s annual meeting.

“We have a crisis, not only in this country, but around the world, because we are not adequately treating osteoporosis,” Douglas Kiel, MD, MPH, American Society for Bone and Mineral Research (ASBMR) president and professor of medicine at Harvard Medical School, said during a press conference. “In fact, we have new evidence that the 30-year downward trend for hip fractures in the United States ... has now hit a plateau in the last few years. We’re here ... to raise a flag that something must be done.”

By 2050, the worldwide incidence of hip fracture is projected to increase by 310% in men and 240% in women compared with the rates seen in 1990. That increase is likely due to a marked decline in the rate of DXA testing, leading to a decline in diagnosis and treatment of the most high-risk patients, said Kenneth Saag, MD, president of the National Osteoporosis Foundation and co-chair of the National Bone Health Alliance.

In addition, current data show that half as many patients are prescribed an osteoporosis treatment today as in the mid-2000s, whereas hip fractures are on the rise worldwide, Saag said.

“The benefit that we saw potentially attributed to the aggressive management of osteoporosis in years past has evaporated,” Saag said. “While we can’t prove a causal relationship of lost testing and treatment with the plateauing in the previously declining rate of fractures, these trends are extremely concerning and highlight a new crisis in our management of osteoporosis.”

Patient perceptions

Despite a plethora of highly effective drugs available to prevent and treat osteoporosis, many patients fear the therapies, often citing the risk for unusual fractures with bisphosphonate therapies, Sundeep Khosla, MD, director of clinical and translational science for the Mayo Clinic, said during the press conference.

“When I tell patients about the different options, their overwhelming concerns are about the rare side effects that have been reported for these drugs,” Khosla said. “It’s difficult as a physician and as a researcher to convey the risk–benefit ratio to the patient. I can tell them, for example, that if they were treated for 5 years, there would be less than one atypical femur fracture caused for 100 osteoporotic fractures that are prevented.”

Khosla said reporting statistics to patients does not dispel their fears of adverse events. “Their argument is, ‘If I’m the one who gets the fracture, it’s not that rare.’ ... As a society and as a field ... we need to let our patients know that we have heard their concerns and come up with new approaches to address their concerns.”

Results from a recent survey underscore patient fears, Andrea Singer, MD, medical director of the National Osteoporosis Foundation (NOF), said during the press conference. In July, NOF and Inspire, an online patient-engagement platform, conducted an 80-question survey via email of NOF’s community members and their caregivers; 853 people responded during a 2-week period.

Among survey respondents, 52% had experienced a broken bone, but nearly half said they were not concerned or did not see a link with future fracture, Singer said.

In addition, nearly 40% of those prescribed an osteoporosis therapy said they never started it; among patients on therapy, 92% said they had read or viewed negative information about the medication, whereas 30% who started a medication had stopped taking it. More than 40% of respondents were not treated for longer than 2 years, she said.

“When you look at the reasons for this, the top reasons they gave were having experienced side effects or, more importantly, the concern about side effects or rare events,” Singer said. “The second most common reason was being unsure of the benefit of the medication.”

Survey results also confirmed that about 60% of those who had broken a bone had not been referred for a bone density test after the fracture; less than half received medication after the fracture, Singer said.

“Clearly, we still have a lot to do when it comes to educating our patients and really putting risk in perspective,” she said.

The care gap

There is a great variation from country to country in the number of individuals at risk for fracture compared with the number of individuals who get treatment, said John Kanis, MD, president of the International Osteoporosis Foundation.

“In Spain, the care gap is relatively small; 80% of high-risk individuals get treatment,” Kanis said. “In Sweden, which has one of the highest hip fracture rates in the world, the care gap is inverse of that; 80%. In other words, only 20% of individuals at high risk get treatment. The good news is because of this variation, we know it can change. We need to understand systems in different countries and take some intelligence from that.”

Kanis said clinicians have to work harder to allay the fears related to treatment on a worldwide basis.

In the call to action, 34 organizations pledged to intensify their efforts and collaborate on new opportunities to increase screening, diagnosis and treatment, and to partner with patients to make informed choices about osteoporosis management. The statement also calls for the following:

Health professional education programs and continuing medical education programs to expand education for health care professionals to focus on recognizing, diagnosing and treating patients at high risk for fracture, with clear messages to inform patients and clinicians about the risks for osteoporosis and fractures.

Increased focus and support from government organizations for programs to reach the patients at highest risk, to ensure access to testing and to all currently available and future therapies.

Insurance coverage (public and private) for the most effective services to improve diagnosis and treatment of those at the highest risk.

Health systems and medical practices to adopt and use quality measures that provide incentives to clinicians and health systems to screen for osteoporosis.

“As we move forward, we need to keep at the forefront our patients and their families and do everything that we can to reduce their risk for debilitating fractures,” Kiel said. – by Regina Schaffer

Reference:

Saag K, et al. Call to Action to Address the Crisis in the Treatment of Osteoporosis. Presented at: ASBMR 2016; Sept. 16-19, 2016; Atlanta.

Disclosure: The researchers report no relevant financial disclosures.