People who have suffered a fragility fracture, which is a fracture resulting
from any fall from a standing-height or less, are at a significant risk for
future fractures. Despite the prevalence of these fractures, especially in
women, there has been a dramatic lack of attention to this issue in the United
States. Assessment and treatment can reduce the risk of fracture and future
morbidity. Since there are no obvious symptoms of osteoporosis, a fracture is
often the first indicator of a problem. By this time, the condition can be
quite advanced. For example, women who suffer a hip fracture have a four times
greater risk of subsequent osteoporotic fractures.
1
Evaluation and treatment of women who have had a fragility
fracture
The National Osteoporosis Foundation guidelines recommend that women ages 50
and older receive pharmacological therapy for bone loss if they have a history
of hip or spine fracture or have experienced another type of fracture and show
reduced bone mass (a T-score between -1.0 and -2.5) when tested using
dual-energy X-ray absorptiometry (DXA).
2
A bisphosphonate drug is the primary medication choice for most women. Multiple
studies confirm the effectiveness of bisphosphonates in preventing vertebral,
nonvertebral, and hip fractures. Alendronate, a drug available in generic form,
has been shown to cut in half the number of hip and spine fractures over three
years in women who have had a previous fracture. It is also approved by the
U.S. Food and Drug Administration for use in women with early bone loss.
Additional medications including estrogens and sex hormone combinations are
also available to women who experience menopausal symptoms, but the choice of
drug ultimately depends on the individual patient?s risk profile and preference.
When possible, physicians should consider generic formulary options so members
can maximize their health plan benefits. Please refer to the listing of
osteoporosis therapies in the table below.
Osteoporosis medications*
Description
Prescription
Bisphosphonates
Alendronate
Alendronate-cholecalciferol
Calcium carbonate-risedronate
Ibandronate
Risedronate
Zoledronic acid
Estrogens
Conjugated estrogens
Conjugated estrogens synthetic
Esterified estrogens
Estradiol
Estradiol acetate
Estradiol cypionate
Estradiol valerate
Estropipate
Other agents
Calcitonin
Denosumab
Raloxifene
Teriparatide
Sex hormone combinations
Conjugated estrogens ? medroxy-progesterone
Estradiol-levonorgestrel
Estradiol-norethindrone
Estradiol-norgestimate
Ethinyl estradiol-norethindrone
*2013 HEDIS Table OMW-C: FDA- Approved Osteoporosis
Therapies
For more information about coverage and precertification requirements for
treatment options, review our medical policies for osteoporosis treatments. Go
to
www.ibx.com/medpolicy, select
Accept and Go to Medical Policy Online, and then type "osteoporosis" in
the Search box.
Physicians may also wish to review the patient's current medication list to see
if they can eliminate drugs that increase the risk of osteoporosis, such as
corticosteroids, heparin, aromatase inhibitors, and some anti-epilepsy
medications. The patient should also be evaluated for conditions that
exacerbate bone loss, including hyperparathyroidism, hyperthyroidism,
malnutrition, malabsorption, and liver disease. Note: The question of whether
to perform routine DXA testing on patients taking bisphosphonate medications
has been the subject of controversy. Analysis from the Fracture Intervention
Trial indicates that there is no benefit to repeating scans within the first
three years of treatment.
3
It is important for physicians to follow up after therapy is initiated to
ensure that patients continue their treatment regimen. One of the major
obstacles to osteoporosis treatment is patients? failure to take their
medication due to restrictive dosing schedules or unpleasant side effects.
Medication adherence can be markedly improved by regular phone calls or direct
contact with the patient to address these problems.
4 Patients may
also benefit from health coaching to support healthful diet, exercise, and
lifestyle choices and assess ongoing fracture risk.
References
1 National Osteoporosis Foundation. Fast
Facts. 2011. http://www.nof.org/node/40
2 Health Dialog. Information for the
healthcare provider: Osteoporosis testing after fractures. 2011.
3 Bell KJ, et al. Value of routine monitoring
of bone mineral density after starting bisphosphonate treatment: secondary
analysis of trial data. BMJ. 2009; 338:b2266.
4 Waalen J, et al. A telephone-based
intervention for increasing the use of osteoporosis medication: a randomized
controlled trial. American Journal of Managed Care 2009 August;
15(8):e60-e70.