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Routine bone density monitoring improves medication use in osteoporosis
A cohort of women with osteoporosis who underwent routine bone mineral density monitoring in the 5 years after initiating therapy were less likely to experience a major osteoporotic fracture and more likely to adhere to treatment when compared with women who did not undergo monitoring, according to findings published in the Journal of Bone and Mineral Research.
“There is controversy about whether continuing BMD monitoring when people start anti-osteoporosis therapy is useful,” William D. Leslie, MD, MSc, FRCPC, professor of medicine and radiology at the University of Manitoba, Winnipeg, told Endocrine Today. “[American College of Physicians] guidelines state such monitoring is not necessary, so long as there is clinical follow-up. However, many guidelines from expert societies promote BMD monitoring. You can make an argument both ways. No one has conducted a randomized trial to see if monitoring makes a difference.”
Using a registry-based cohort from Manitoba, Canada, Leslie and colleagues compared anti-osteoporosis medication use and fracture outcomes in women aged at least 40 years who underwent BMD monitoring within 5 years of initiating therapy (n = 4,559; mean interval, 3.2 years) who were propensity-score matched with similar women who did not undergo BMD monitoring (n = 4,559). Researchers used a population-based retail pharmacy database to assess anti-osteoporosis medication use over 5 years and health services data to assess incident fractures to 10 years.
During a median 10 years of observation, 1,223 (13.4%) women developed major osteoporotic fractures, including 591 monitored women and 632 women who did not undergo monitoring (31% vs. 13.9%; P = .208). Women who underwent monitoring also sustained fewer hip fractures when compared with those who were not monitored (3.7% vs. 4.7%; P = .012).
Researchers found that monitored women had better fracture-free survival for major osteoporotic fracture, with a 1.9% lower 10-year cumulative risk (P = .04) and a 1.8% lower cumulative risk for hip fracture (P = .001) when compared with women who were not monitored. HRs were lower in monitored vs. not monitored women for major osteoporotic fracture (HR = 0.89 = 95% CI, 0.8-0.98) and hip fracture (HR = 0.74; 95% CI, 0.63-0.87). The women who were monitored also had more days of medication use, a greater medication persistence ratio and more treatment switching in the 5 years after initiating therapy, the researchers noted.
“I was somewhat surprised, but pleasantly so, to see that the group who received monitoring had better adherence to medication, and more switching of medications, which was consistent with changes in bone density,” Leslie said in an interview. “This is what you expect to happen if you are going to act on results. At the end of the day, there was a statistically significant reduction in fractures in the monitoring group.”
At the end of 5 years, more women in the monitored group persisted on treatment and more switched treatment, with switching behavior associated with an observed interval reduction in BMD, the researchers wrote.
“This makes a case that BMD monitoring may have some value,” Leslie said. “In the absence of a randomized controlled trial, it provides food for thought and may contribute to more discussion about monitoring.” – by Regina Schaffer
For more information:
William D. Leslie, MD, MSc, FRCPC, can be reached at the Department of Medicine, C5121, 409 Tache Ave., Winnipeg, Manitoba, Canada, R2H 2A6; email: bleslie@sbgh.mb.ca.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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It is common sense that patients prescribed long-term medications for a lifelong disease be monitored to evaluate response to treatment. As examples, it is standard practice to repeat blood pressure measurements in patients treated for hypertension and repeat glucose and HbA1c measurements in patients treated for diabetes. When the response is suboptimal, further evaluation and modification of the treatment plan may be indicated.
With patients treated for osteoporosis, another lifelong disease in need of long-term treatment, it is also common sense to monitor for treatment effect. This is most often done by repeating BMD measurement, which is recommended in many, but not all, clinical practice guidelines. In support of monitoring BMD are reports of a strong correlation between an increase in BMD with treatment and reduction of fracture risk. Achievement of a T-score greater than –2 has been suggested with treat-to-target for osteoporosis. Loss of BMD may represent a suboptimal response to therapy and the need for evaluation for possible causes and consideration of a change in therapy.
The study by Leslie and colleagues provides additional support for monitoring BMD in treated patients, with evidence that patients who have BMD monitoring are more adherent to therapy and have better clinical outcomes than those who are not monitored. BMD monitoring is recommended by organizations that include the Endocrine Society, American Association of Clinical Endocrinologists, National Osteoporosis Foundation, and International Society for Clinical Densitometry. I suggest that clinicians use common sense, supported by the medical evidence, in following these guidelines to make effective use of BMD monitoring to improve the care of patients with osteoporosis.