Complex Cases in Primary Care: Osteoporosis

CLINICIAN RESOURCES

Fracture Risk Assessment Tool (FRAX)

To help clinicians identify patients who have a high risk of experiencing an osteoporosis-related fracture and to help inform treatment decisions, the World Health Organization developed a fracture risk assessment tool (FRAX) for use in treatment-naïve patients. The tool determines a patient’s absolute fracture risk using a combination of clinical risk factors, with or without the results of femoral neck bone mineral density testing. This tool can also be used to educate patients; showing treatment-naïve patients their 10-year probability of experiencing an osteoporosis-related fracture may help motivate them to adhere to recommendations for screening, prevention, and treatment: www.shef.ac.uk/FRAX/tool.aspx?country=9

Assessing for Occult Vertebral Fractures

Although two-thirds of vertebral fractures are clinically silent, they are associated with up to a 3-fold increase in the risk of subsequent fractures. This article by Green and colleagues outlines physical examination tests that can detect these silent events before a symptomatic fracture occurs, including the wall-occiput test for occult thoracic vertebral fractures and the rib-pelvis distance test for occult lumbar vertebral fractures.
Green AD, Colon-Emeric CS, Bastian L, et al. Does this woman have osteoporosis? N Engl J Med. 2004;292:2890-2900.  www.ncbi.nlm.nih.gov/pubmed/15598921

Evidence-Based Treatment Guidelines

Guidelines for assessing patients for the risk of osteoporosis have been published by several national organizations, including the American Association of Clinical Endocrinologists (AACE) and the National Osteoporosis Foundation (NOF), among others:
www.nof.org/files/nof/public/content/file/344/upload/159.pdf
www.aace.com/files/osteo-guidelines-2010.pdf

PATIENT RESOURCES

Patient Education

The Web site of the Hormone Health Network, the public education affiliate of The Endocrine Society, posts downloadable, easy-to-print fact sheets and a patient guide on several topics related to osteoporosis for healthcare professionals to share with their patients. Fact sheets address topics such as benefits and risks of bisphosphonates, menopause and bone loss, and the role of vitamin D and calcium in bone health, among others; the patient guide provides a brief overview of osteoporosis in men, an often overlooked subset of this patient population:

Vitamin D Supplementation

Recommendations for adequate levels of vitamin D intake are controversial and have recently been in flux. Patients may feel confused by conflicting news stories and unsure as to whether they should take vitamin D supplements to improve their bone health and protect against fractures. A September 2012 article in Harvard Women’s Health Review provides good, practical guidance on rational approaches for vitamin D and calcium supplementation:
www.health.harvard.edu/newsletters/harvard_womens_health_watch/2012/September