A paradigm shift in how we view, diagnose, and treat osteoporosis is much needed, Professor John Bilezikian , Silberberg Professor of Medicine and Pharmacology at the College of Physicians and Surgeons, Columbia University, told delegates attending the Amgen One Scientific Symposium.

Talking to delegates during the bone symposium of the conference held in Melbourne, Prof. Bilezikian , posed a deceptively simple question to delegates. “How do we diagnose osteoporosis?” he asked. “Its sounds simple, right? Well we might have made it too simplistic.”

The obvious answer is dual-energy X-ray absorptiometry (DEXA) scan and T-score less than -2.5 at the lumbar spine or hip. However, Prof. Bilezikian pointed out this diagnostic criterion has limitations as “postmenopausal women who sustain osteoporotic fractures might miss out on diagnosis. Especially when most women who have a hip fracture, do not have an osteoporotic T-score. The cut-offs are so black and white in the United States.”

Professor Bilezikian drew an interesting parallel that “a heart attack without an elevated LDL cholesterol level is still coronary artery disease, while a fragility fracture without an osteoporotic T-score is still osteoporosis!”

How should we diagnose osteoporosis?

Prior to the DEXA era (pre-1986), osteoporosis was diagnosed based on fragility fractures, but Professor Bilezikian told delegates he believed this had been forgotten. “A prior fragility fracture is the greatest risk factor for subsequent fractures, regardless of a T-score which indicates ‘osteoporosis’. The fracture begets the fracture begets the fracture……” he noted.

To demonstrate, Prof. Bilezikian presented data from a large retrospective cohort study of over 3 million patients in the USA.^1,2 The study revealed 76% of postmenopausal women with a distal radial fracture were not diagnosed or treated for osteoporosis.^1,2 “There are also other studies that show patients were not receiving routine chest X-rays and vertebral fractures were frequently unrecognised.³ Despite being a strong risk factor for subsequent fractures and guidelines emphasising BMD testing and osteoporosis treatment, another study in 2013 highlighted most patients were not tested or treated for osteoporosis after a fragility fracture,⁴” he said.

Professor Bilezikian noted that a second fracture “can be prevented by identifying the first fracture.” Other aids to help identify patients likely to have a fracture include risk assessment tools like FRAX or Garvan. He also drew attention to falls risk as a result of patient risky behaviour, balance, and sarcopenia. “It is evident that there is merit in considering risk factors besides bone mineral density (BMD) to predict the likelihood of an osteoporotic fracture,” he noted. For example, he posed the following questions:

“Does someone whose blood pressure becomes normal with treatment still have the diagnosis of hypertension?

Does someone whose cholesterol level becomes normal with treatment still have the diagnosis of hypercholesterolemia?

Does someone whose HbA1c becomes normal with therapy still have the diagnosis of diabetes mellitus?”

According to Prof. Bilezikian one prevalent fallacy was that when a person’s T-score had shown improvement, they could cease osteoporotic treatment.⁵ He noted, all osteoporotic treatments once discontinued are associated with bone loss, including bisphosphonates.⁶ “We need to keep in mind that no current treatments for osteoporosis completely restore the disordered bone microstructure. If patients incorrectly perceive their osteoporosis is ‘cured’ we may face challenges in adherence to medication. This may be further complicated if prescribing criteria are centred on a specific T-score. Once a patient’s T-score is above -2.5, their therapy might not be subsidised in the United States at least, and this proves to be an issue with osteoanabolics and denosumab,” he remarked.

“Clearly, a paradigm shift in how we view, diagnose and treat osteoporosis is much needed. The criteria for diagnosing osteoporosis should encompass more than just BMD T-score, they should also include fragility fractures, risk assessment tools and falls risk assessment. In essence, osteoporosis is osteoporosis is osteoporosis; effective therapy does not alter the diagnosis,” Prof. Bilezikian concluded.

This article was sponsored by Amgen, which has no control over editorial content. The content is entirely independent and based on published studies and experts’ opinions, the views expressed are not necessarily those of Amgen.

References

1. Freedman KG, et al. J Bone Joint Surg 2000;82A:1063-70.
2. Siris E, Bilezikian JP et al. J Clin Endocrinol Metab 88:2003.
3. Gehlbach SH et al. Osteoporos Int. 2000;11:577.
4. National Committee for Quality Assurance. The State of Health Care Quality 2014. October 2014.
5. Lewiecki EM, Binkley N, Bilezikian JP: Treated Osteoporosis is still Osteoporosis. J Bone Miner Res 2019 (in press).
6. Curtis et al. ASBMR, 2018.