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Critical Challenges – Diagnosis and Treatment of Osteoporosis

Two critical challenges faced in the diagnosis of osteoporosis are difficulties in diagnosing osteoporosis in diabetic patients, and under-diagnosing of osteoporosis by physicians. Two critical challenges faced in the treatment of osteoporosis are convincing patients suffering from osteoporosis to take long term treatment, and the unreliability of the assessment of fracture risks.

CRITICAL CHALLENGES IN DIAGNOSIS

1. DIFFICULTY IN DIAGNOSING OSTEOPOROSIS IN DIABETIC PATIENTS

2. OSTEOPOROSIS IS UNDERDIAGNOSED BY PHYSICIANS

  • A critical challenge faced in the diagnosis of osteoporosis is that the disease is under-diagnosed by physicians. This happens even after fractures have occurred in high-risk patients. The effect is that more fractures are likely to occur in the patient in the future because of missed opportunities to diagnose and treat the illness. High-risk patients such as perimenopause women should be advised to start treatment to reduce the risk of fractures instead of waiting for a diagnosis of osteoporosis.
  • Under-diagnosis occurs because physicians are regularly overburdened with several responsibilities such as administrative, clinical, and regulatory responsibilities, leaving very little time to assess the disease. Also, patients with fractures often receive treatment from emergency department specialists or orthopedists who are not involved in the continuous care of the patient and the prevention of future fractures.

CRITICAL CHALLENGES IN TREATMENT

1. CONVINCING PATIENTS TO TAKE LONG TERM TREATMENT

  • Physicians face the critical challenge of convincing patients suffering from osteoporosis to take long term treatment. This is because patients may not be comfortable to continue with the treatment due to unbearable side effects such as atypical femoral fracture or osteonecrosis of the jaw.
  • This affects the treatment process because if patients stop taking treatment, the risk of fractures increases. Physicians can help patients feel comfortable being on long term treatment by revealing the downside of not receiving treatment for the disease, instituting a predictable treatment schedule, and trying to meet patient preferences in terms of things like dosage.

2. UNRELIABILITY OF FRACTURE RISK ASSESSMENT

  • A challenge faced by physicians in the treatment of osteoporosis is the unreliability of the assessment of fracture risks. This includes the use of dual-energy x-ray absorptiometry (DXA) and the fracture risk assessment tool (FRAX). According to specialists in osteoporosis, most fractures happen in women with osteopenia, and not osteoporosis. The DXA scan is unreliable as it only gives a two-dimensional image when the density of bones is affected by various factors such as bone thickness and osteoarthritis.
  • Moreover, the DXA scan doesn’t show all changes in the bone which could be used to differentiate between osteoporosis and osteopenia. Also, the FRAX score does not provide a reliable means to assess the risk of fractures in high-risk groups, such as those who are obese, those with type 2 diabetes and sarcopenia. Inaccuracy in fracture risk assessment affects the treatment process by limiting the information needed by physicians to provide quality treatment.

RESEARCH STRATEGY

To find critical challenges faced in the diagnosis and the treatment of osteoporosis, our strategy was to search for relevant information in credible publications and trusted academic sources. This strategy led us to sources such as Med Page Today and Touch Endocrinology which provided information on challenges and which were included in our findings.

Concept Overview – Physician Persistence; Treatment of Osteoporosis

While studies show that osteoporosis treatments are beneficial to older patients with multiple diseases or issues, patient reluctance and lack of knowledge of the medications available cause doctors to give up on instructing patients on the benefits of treating osteoporosis.

Physician Persistence — Treatment of Osteoporosis

Overview

  • Osteoporosis is when the bone structure deteriorates, becoming frail and creating an increase in the risk of fracture.
  • This disease can affect men and women and can be prevented and treated.
  • Currently in the United States, over 53 million people have osteoporosis or may develop the disease because of low bone mass.
  • The prevention of fractures is important to many older adults. In a survey of elderly women, 80% said they would rather die than be institutionalized with a fractured hip.

Treatment Overview

  • A study from JAMA notes that the chance of a fracture caused by osteoporosis increases exponentially as one ages.
  • Screening and treatment of osteoporosis in patients in their eighties and nineties is not as likely as for younger patients.
  • Treatment guidelines for osteoporosis follow a ten-year risk assessment but these guidelines do not address patients with a less than 10 year life expectancy, or patients with other diseases.
  • The American Academy of Family Physicians reports that it is recommended to begin screening for osteoporosis with duel-energy x-ray absorptiometry (DEXA) for women with no risk factor at age 65 and in men with no risk factor at age 70.
  • Adding calcium and vitamin D supplements are not enough to manage an elderly patient’s osteoporosis.
  • Older patients and their doctors are often concerned with multiple prescriptions and possible side effects. It is recommended that physicians should discuss patient priorities when deciding on treatment for osteoporosis.
  • Currently, the American Association of Clinical Endocrinologists and the American College of Physicians give guidelines that patients who are diagnosed with osteoporosis are to be treated with an antiresorptive agent to reduce vertebral and hip fractures.
  • But, they do not agree on the length of treatment or how long a patient’s bone density is monitored during or after the osteoporosis treatment.

Fear of Medications

  • Bisphosphonates are used for treating osteoporosis and are very effective. They can reduce spine fracture risk by 70% and hip fracture risk by 50%.
  • Some seniors are afraid to take these drugs because in rare cases they can cause atypical femur fractures or crumbing jaws.
  • In a National Institutes of Health (NIH) study, women over 55 had a 50% decline in using oral bisphosphonate which was at the same time as reports in the media over safety concerns for Fosamax (brand name for bisphosphonates).
  • “According to some estimates, treating 1000 women with osteoporosis with bisphosphonates for 3 years might cause up to 1.25 atypical femur fractures, while preventing approximately 100 osteoporotic fractures“.

Lack of Treatment

  • An 2012 international study noted that over 80% of elderly women who’d had fragility fractures were not being treated with medication for osteoporosis.
  • A 2014 study noted that in women over 50, during the year after a hip fracture hospitalization, use of osteoporosis medications were decreased from 40% to 21%.
  • Another study from 2015 noted that 60% of women who began oral osteoporosis medications had stopped taking them within one year.
  • Medicare recently published that there were 11,000 more hip fractures from 2013-2015 in women over 65 than what was predicted.
  • Meryl Susan LeBoff, MD, director of the Skeletal Health and Osteoporosis Center at Brigham and Women’s Hospital in Boston notes that not all doctors realize that a fracture in an older patient might be osteoporosis and that an evaluation should be scheduled.
  • Carolyn Crandall, MD, internist at the University of California Los Angeles Medical Center believes that many doctors don’t know the statistics for adverse effects for bisphosphonates and can’t inform patients who are worried about taking medications for osteoporosis, leaving their patients with no treatment.
  • Sundeep Khosla, MD, osteoporosis clinician and researcher at the Mayo Clinic, states that doctors must address patients’ concerns about drug treatments, and build the patient’s trust.

Treating Older Patients with Multiple Conditions

  • Centers for Disease Control and Prevention states that 85% of the elderly have at least one chronic health condition and 60% of the elderly have least two.
  • The National Institute on Aging recommends that doctors spend time and educate older patients on what conditions they have. Doctors should answer questions and have information that the patient may not know to ask about.
  • Doctors should make sure the explanation of the diagnosis is clear and that the patient understands what is happening.
  • Treatment information should be provided and fears about side effects and costs should be addressed.
  • Care givers should be a part of these discussions.

Pharmacological Treatment

  • One study notes that it is never too late to begin treatment for osteoporosis even when an elderly patient has the disease and has had a fracture due to the disease.
  • This study notes that treatment of frail older patients with osteoporosis may be more effective that treatment in younger patients, because more fractures are avoided, leading to a reduced number of treatments.
  • Osteoporosis treatments available are safe and reduce fracture risk with documented results for vertebral fractures and hip fractures.
  • The College of Physicians and Surgeons of Alberta state not that patients with multiple conditions increase the chance of adverse drug to disease and drug to drug interactions. Renal function can be the great problem. Managing care must be individualized to consider the patient’s life expectancy, benefit from drug therapy, and treatment goals.

New Study — Treatment in Women over 80

  • In a newly released study by JAMA, it was concluded that women over 80 with osteoporosis, even if they have other ailments or diseases, would still be good candidates for drug treatments to prevent hip fractures in the future.
  • Sarah D. Berry, MD, MPH, Sandra Shi, MD and Douglas P. Kiel, MD, MPH commented on the newly released study and believe that clinical guidelines for osteoporosis should include information on patients with multiple diseases.
  • The doctor’s comments also indicated they think treatment that are effective for older patients with osteoporosis, even with other diseases, are as effective as they are for younger patients, then the treatment is more beneficial than the risk. However, the doctors agree it is ultimately up to the patient to decide if treatment for osteoporosis is what they want.

RESEARCH STRATEGY

Despite an extensive search, we were unable to fully answer if physicians give up diagnosis/treatment as their osteoporosis patients age or develop other health issues. We began our search with government medical sites such as the National Institute on Aging, Agency for Healthcare Research & Quality, and National Institute of Health, looking for information on treating osteoporosis. We were able to find information on what this disease is, along with testing and treatment information but we did not find information on the number of doctors who are treating osteoporosis, or when or if they discontinue treatment. We then reviewed medical portals such as the JAMA, Johns Hopkins Arthritis Center, and Dove Medical Press for articles on doctors treating osteoporosis. We were able to find new studies on osteoporosis, benefits of treatments for patients with this disease, and care for elderly patients and caregivers. We have included the newest studies in this report. We were also able to find information on caring for elderly patients with multiple conditions. However, none of these studies contained information when doctors stop treating osteoporosis. We then searched university research and medical school sites such as the University of New Mexico Health Sciences and National Academy of Sciences looking for patient studies for osteoporosis. Here, we located an article with several doctors thoughts on how physicians care of osteoporosis patients that is included in this report. However, this information is very limited and we did not find information on doctors who alter care due to age or health issues. Many studies and articles mention that care and treatment for osteoporosis should be discussed and evaluated between the doctor and the patient. We believe this is why there is limited information on when physicians stop care for elderly osteoporosis patients.

TDM

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