Best Practices in Managing Fracture Risk

Mercy Health - Cincinnati, which provides advanced, quality, compassionate care in your neighborhood through its care network, announces that the Journal of the American Medical Association has published best practices from Mercy Health Physician Nelson Watts, MD to assist primary care physicians in evaluating and managing patients’ osteoporosis and fracture risk.

“Fractures due to osteoporosis represent a serious and costly public health problem, leading to disability and increased mortality risk. For post-menopausal women, osteoporotic fractures are more common than stroke, heart attack and breast cancer combined and can represent a significant threat to personal independence,” says Dr. Watts, an internationally-renowned osteoporosis expert.

“Primary care doctors play a key role in detecting patients’ fracture risk and these guidelines can help them be comfortable evaluating, preventing and treating osteoporosis and related risks for the benefit of their patients.”

Dr. Watts recommends that primary care physicians take the following steps to assess their patients and identify their risk for fractures:

• Determine which patients have had fractures in adulthood to the humerus, radius, femur, vertebra or pelvis
• In the absence of fracture, around age 50 years, ask patients about factors associated with increased fracture risk such as low body weight, early menopause, family history of osteoporosis and selected diseases and medications known to increase fracture risk (glucocorticoids, proton pump inhibitors, selective serotonin reuptake inhibitors)
• In the absence of risk factors, have women by age 65 and men by age 70 take a bone mineral density measurement using dual-energy x-ray absorptiometry (DXA). Do this sooner if the patient has a significant fracture or one or more clinical risk factors.
• When considering medications to reduce fracture risk, assess patients’ blood count, chemistry panel and 25-hydroxyvitamin D count first to ensure there are no contraindications due to reduced kidney function or other health issues

For patients that doctors determine are at high risk of fraction, Dr. Watts recommends the following to manage their care:

• At least one visit devoted to patient education about osteoporosis, fracture risk and medication choices
• Stress adequate calcium and vitamin D intake and recommend weight-bearing and resistance exercise
• Consider prescribing one of several pharmacologic agents to reduce fracture risk
• Oral options: alendronate or risedronate
• Nonoral options: denosumab, teriparatide, and zoledronic acid (consider referral to osteoporosis specialist)
• Identify and address nonskeletal risk factors for falling and fracture, such as problems with vision, hearing and balance and home safety issues, such as floor rugs
• Reassess patients’ progress periodically (every one to two years)

“It’s important for patients to have the opportunity to discuss their results and work with their doctor to develop a management plan that works for them. Patient understanding is important to patients accepting and taking an active role in managing their fracture risk,” says Dr. Watts.

Dr. Watts’ guidelines appeared in JAMA on December 12. JoAnn E. Manson, MD, DrPH of Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts and Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts contributed to the article.