Is there any difference between primary and secondary prevention for patients with osteoporosis?



1. J. R. Caeiro Rey, Spain
2. H. Canhão, Portugal
3. A. El Garf, Egypt
4. O. Ershova, Russia
5. T. S. Fu, Taiwan
6. D. Grigorie, Romania
7. J. Li-Yu, Philippines
8. M. O’Brien, Ireland
9. V. Povoroznyuk, Ukraine
10. S. Rojanasthien, Thailand
11. E. Rudenka, Belarus
12. G. Singh, Malaysia
13. B. Stolnicki, Brazil


1. J. R. Caeiro Rey, Spain

José R. CAEIRO REY, MD, PhD
Coordinator of the Osteoporosis and Osteoporotic Fracture Study and Research
Group of the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT-GEIOS)
Associated Professor of Orthopaedic Surgery and Traumatology and Coordinator of the Adult Trauma Unit, Orthopaedic Surgery and Traumatology Department, University Hospital
of Santiago de Compostela, Santiago de Compostela, University, SPAIN
(e-mail: Jrcaeiro@telefonica.net jrcaeiro@trabeculae.com)



Nonpharmacological and pharmacological recommendations have different levels of evidence regarding their efficacy in primary or secondary prevention, and it is necessary to provide patients with valid preventive advice according to these data and their risk of osteoporotic fracture. Several nonpharmacological recommendations can be considered universal1 for primary and secondary fracture prevention.1,2 Cessation of tobacco, identification and treatment of patients with excessive alcohol intake (≥3 units per day) are useful lifestyle recommendations, regardless of risk level.1,2 Although they have a weak impact on fracture outcome, they are still recommended because general health benefits from them. Appropriate dietary protein consumption (1g/kg/day), and adequate calcium (1000-1200 mg per day including supplements) and vitamin D intake (800-1000 IU vitamin D3 per day including supplements for adults ≥50 years) contribute to bone health and reduce the risk of osteoporotic fractures.1,2

Regular weight-bearing (walking, dancing, etc) and muscles-trengthening exercise averts bone loss, reduces the risk of falls and fractures, and imparts general health benefits.1,2 Fall prevention strategies (falling risk factors assessment, home safety improvement, maintenance of vitamin D levels, etc) are first-line secondary prevention recommendations.1,2 Hip protectors are cost-effective in reducing hip fractures among residents in nursing homes.2

Actually, the major pharmacological interventions for primary and secondary prevention of osteoporotic fractures are antiresorptive agents (bisphosphonates, denosumab, selective estrogen receptor modulator [SERMs]), anabolic agents (teriparatide and parathyroid hormone–derived agents), and dualaction drugs (strontium ranelate).1,2

The bisphosphonates alendronate and risedronate are approved for the prevention and treatment of osteoporosis in postmenopausal women, and for the treatment of osteoporosis in men.1-4 Ibandronate is only approved for the treatment of osteoporosis in postmenopausal women.11 Denosumab is approved for osteoporosis treatment in postmenopausal women at high risk of fracture and to increase bone mass in men with osteoporosis at high risk of fracture.1 Raloxifene is approved for osteoporosis prevention and treatment in postmenopausal women.1 Bazedoxifene can be used as an alternative to raloxifene.2 Teriparatide is approved for osteoporosis treatment in postmenopausal women and men who are at high risk of fracture.1,3,4 Strontium ranelate is recommended for the treatment of severe osteoporosis in postmenopausal women at high risk of fracture and for the treatment of severe osteoporosis in men at increased risk of fracture.3,4

Overall, preventive pharmacotherapy reduces the risk of vertebral fracture by 30% to 70%, depending on the agent used and on patient compliance.2,5 The effect on nonvertebral fractures is generally lower and varies by fracture site. However, only some drugs have been shown to reduce the risk of nonvertebral fractures, and just a few drugs specifically decrease the risk of hip fracture.1,2 For hip fractures, the relative reductions in risk range from 30% to 51%.5

When choosing a particular pharmacological agent one should keep in mind that agents found to decrease vertebral, nonvertebral, and hip fractures should be used preferentially over those that only demonstrate vertebral antifracture efficacy. As a general rule, preventive or therapeutic pharmacological decisions should be based on a balance between the benefits and risks for each particular patient, as no single agent is appropriate in all circumstances and for all patients.5


References
1. National Osteoporosis Foundation. Newly Revised 2013 Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013. Available at: http://www.nof.org/files/nof/public/content/resource/ 913/files/580.pdf.
2. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013; 24(1):23-57.
3. National Institute for Health and Clinical Excellence. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. NICE technology appraisal guidance 160. Quick reference guide. London, UK: National Institute for Health and Clinical Excellence; October 2008. Available at: http://www.nice.org.uk/nice media/live/11746/42486/42486.pdf (Accessed August 10, 2013).
4. National Institute for Health and Clinical Excellence. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. NICE technology appraisal guidance 161. Quick reference guide. London, UK: National Institute for Health and Clinical Excellence; October 2008. Available at: http://www.nice. org.uk/nicemedia/live/11748/42508/42508.pdf (Accessed August 10, 2013).
5. Reginster JY. Antifracture efficacy of currently available therapies for postmenopausal osteoporosis. Drugs. 2011;71(1):65-78.

2. H. Canhão, Portugal

Helena CANHÃO, MD, PhD
Rheumatology Research Unit
Instituto de Medicina Molecular
Lisbon, PORTUGAL
(e-mail: helenacanhao@gmail.com)



There is a core of measures associated with bone health that should be followed by all individuals regardless of whether or not they have a previous history of fragility fracture.1 Thus, one should answer “No” to the question “is there any difference between primary and secondary prevention for patients with osteoporosis?”

These measures include an adequate intake/supplementation with calcium and vitamin D; adequate weight-bearing and muscle-strengthening exercise to increase agility and balance and decrease the risk of falling; assessment of the risk of falls and adoption of measures to avoid falls; and a reduction in the consumption of alcohol and tobacco. All these factors are important in preventing fractures and should be implemented, together with counseling patients about osteoporosis and fracture prevention, and increasing the awareness and knowledge of all concerned (health professionals included) on osteoporosis and the risk of fragility fractures.

The issues start when moving from nonpharmacological measures to pharmacological treatments, as there are some difficult and debatable questions. Should the fracture be the trigger to start therapy? or should prevention of the first fracture be the main goal, starting treatment long before a fracture occurs? Does the site of the fracture matter? Should primary and secondary prevention be the same for all patients? If not, why and how would they differ?

Many argue that preventing the first fracture should be THE goal, while others claim that pharmacological therapy has only demonstrated robust efficacy in patients with established osteoporosis. There is consensus on the fact that fragility fractures warrant osteoporosis treatment. In fact, secondary prevention for patients with established osteoporosis is recognized worldwide as a standard recommendation. However, data show that there is a lack of diagnosis and treatment of osteoporosis in patients after hip and other fragility fractures. Follin et al reported treatment of osteoporosis in only 25% of patients that suffered a hip fracture at discharge and during the first year of follow-up.2

It is well documented that after a fracture the risk of a subsequent fracture increases by 2- to 3-fold.3 So why are so many patients discharged with no medication after a fragility fracture? One of the reasons that have been pointed out is that physicians lack awareness and knowledge of osteoporosis management. For others, lack of evidence, multiple drugs, and comorbidities may also hamper treatment. Although there is some heterogeneity in clinical practice, pharmacological treatment for secondary prevention in established osteoporosis is recommended and widely used.

Treatment is also recommended for primary prevention in patients with osteoporosis, but the strategy should be individualized according to age, BMD, and other osteoporosis risk factors. The risk of falls and the risk of fracture should be assessed. The nonpharmacological measures described above should be implemented to minimize the risk of fracture, and all modifiable risk factors should be addressed. After a thorough evaluation, pharmacological treatment should be tailored in accordance with patient risk and using drugs with proven efficacy in osteoporosis treatment.4

References
1. National Osteoporosis Foundation. Newly Revised 2013 Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013. Available at: http://www.nof.org/files/nof/public/content/ resource/913/files/580.pdf.
2. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in women and men after hip fracture. Pharmacotherapy. 2003;23:190-198.
3. Eastell R, Reid DM, Compston J, et al. Secondary prevention of osteoporosis: when should a non‐vertebral fracture be a trigger for action? QJM. 2001;94:575- 597.
4. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF).European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24:23-57.

3. A. El Garf, Egypt

Ayman EL GARF, MD, PhD
Professor of Rheumatology
Department of Rheumatology
Cairo University Hospitals
Cairo University
Cairo, EGYPT
(e-mail: Ayman.El-Garf@kasralainy.edu.eg)



Osteoporosis has been defined as “a skeletal disease characterized by compromised bone strength predisposing a person to an increased risk of fracture.”1 “Bone strength primarily reflects the integration of bone density and bone quality.”1 In the absence of a fragility fracture, bone mineral density (BMD) is used for the diagnosis of osteoporosis according to the World Health organization (WHO).2

Usually, the term “primary prevention” means prevention of an osteoporosis-related fracture, through maintaining the BMD above –2.5 SD of the adult normal mean (T-score). On the other hand, “secondary prevention” means treatment after an osteoporosis-related fracture, to prevent a second fracture. Primary prevention of osteoporosis or low BMD aims at maximizing peak bone mass and minimizing the rate of bone loss through nutrition (adequate calcium and vitamin D intake), high impact exercise, cessation of smoking and excess alcohol, etc, with or without pharmacological therapy. Primary prevention is preferable to secondary prevention. Changes in quality, in the form of fatigue damage, microarchitectural changes, and trabecular disconnection associated with osteoporosis are largely irreversible. Treatment at this stage may stabilize or increase BMD and reduce the risk of a second fracture, but is unlikely to restore bone quality and bone strength to a considerable extent.

In elderly (>75 years) or institutionalized people, trials have convincingly shown a lower risk of fracture with supplementation therapy.3 On average, supplementation reduced the risk of nonvertebral fractures (including hip fractures) by 10% to 20%.4 While the value of nutrition and lifestyle modifications is obvious in primary prevention, their value in secondary prevention is less clear. However, vitamin D supplementation enhances intestinal absorption of calcium, as well as optimal muscle function and balance. Low concentrations of vitamin D are associated with impaired calcium absorption, a negative calcium balance, and a compensatory rise of parathyroid hormone. Vitamin D may also reduce the risk of falling, but only at a dose of at least 700 IU per day,5 a factor that may be of critical importance in secondary prevention. Postfracture, the use of calcium plus vitamin D supplements alone or with antiosteoporotic drugs in females was associated with lower mortality in older hip fracture patients.6 Furthermore, in patients with osteoporosis with a previous fracture, antiosteoporotic drugs are usually needed, and all the randomized clinical trials with antiosteoporotic drugs have generally been carried out on a background of calcium and vitamin D supplementation.

In conclusion, lifestyle recommendations are needed for both the primary and secondary prevention of osteoporosis. Their role in minimizing bone loss, maintaining BMD, and lowering fracture risk is obvious in primary prevention. In secondary prevention, high-dose vitamin D (> 700 IU) and calcium supplementation is associated with improved muscle balance, fall prevention, lower mortality after hip fracture, and enhanced efficacy of antiosteoporotic therapy.

References
1. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis Prevention, Diagnosis and Therapy. JAMA. 2001;285:785.
2. WHO Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis (Technical Report Series). Geneva, Switzerland: World Health Organization; 1994.
3. Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med. 1992;327:1637-1642.
4. Boonen S, Lips P, Bouillon R, Bischoff-Ferrari HA, Vanderschueren D, Haentjens P. Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: evidence from a comparative meta-analysis of randomized controlled trials. J Clin Endocrinol Metab. 2007;92:1415-1423.
5. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials. Br Med J. 2009;339:b3692.
6. Nurmi-Lüthje I, Lüthje P, Kaukonen JP, et al. Post-fracture prescribed calcium and vitamin D supplements alone or, in females, with concomitant anti-osteoporotic drugs is associated with lower mortality in elderly hip fracture patients: a prospective analysis. Drugs Aging. 2009;26(5),409-421.

4. O. Ershova, Russia

Olga ERSHOVA, MD, PhD
Yaroslavl State Medical Academy
Yaroslavl, RUSSIA
(e-mail: yarosteoporosis@list.ru)



In order to answer this question, we must first define what primary and secondary prevention of osteoporosis mean. If we consider the severity of the osteoporotic process, osteoporosis prevention should be approached from three perspectives, by avoiding:
◆ The occurrence of osteoporosis (a decrease in bone mineral density [BMD]);
◆ The development of osteoporotic fractures in the presence of osteoporosis;
◆ The development of further fractures after a first prevalent fracture.

In this regard, primary prevention can be considered as prevention of either an early reduction in BMD or the development of low-energy fractures. Therefore, preventive measures should be aimed at achieving the maximum peak bone mass in childhood and adolescence, and are based on the adherence of children to a healthy lifestyle—adequate intake of dairy products, sun exposure, outdoor games, intake of vitamin D supplements in the winter-spring period, etc.

The next important period for primary prevention is the premenopausal and early postmenopausal years, when the inevitable decline in estrogen levels renders it necessary to maintain normal serum levels of vitamin D and calcium in order to constrain accelerated bone resorption and the subsequent decrease in BMD with adequate calcium in the diet, sun exposure and/or intake of calcium and vitamin D supplements, and adequate physical activity. However, if BMD falls to below –2.5 SD, the administration of antiosteoporotic agents is required in order to stabilize (or increase) BMD. The prevention of falls, which relies on the fight against sarcopenia, is also of major significance.

On the one hand, these are primary measures related to preventing the occurrence of fractures, but, on the other hand, they already represent a treatment, and not a prevention of the osteoporotic process. In this sense, they are not different from secondary prevention aimed at reducing the risk of recurrent fractures. For treatment strategies based on the FRAX® tool, the identification and treatment of individuals at high risk of fractures, regardless of (or in combination with) BMD assessment, can also be considered as primary prevention, while secondary prevention will be the prevention of further fractures.

However, preventive measures are universal and include combating risk factors, sufficient intake of dietary calcium, maintaining normal levels of vitamin D in the blood, slowing the decrease in BMD by administration of antiosteoporotic agents in combination with calcium and vitamin D supplements, and the prevention of falls. The choice of drug should be individually tailored and based on the available evidence regarding efficacy and safety, as well as their indications and contraindications. At the same time, from the prevention viewpoint, improving the strength properties of bone tissue is among the priority issues and involves increasing bone mass and improving the quality of bone.

These requirements are completely fulfilled by strontium ranelate, which reduces the risk of both vertebral fractures and peripheral fractures, including proximal femoral fractures, which has been confirmed by the results of well-designed randomized clinical trials.

5. T. S. Fu, Taiwan

Tsai-Sheng FU, MD
Associate Professor
Department of Orthopaedic Surgery
Chang Gung Memorial Hospital in Keelung
Chang Gung University, School of Medicine
Keelung, TAIWAN
(e-mail: fts111@adm.cgmh.org.tw)




The key point of treating osteoporosis is to reduce the incidence of fractures and their sequelae. Primary prevention is intended to prevent the first fragility fracture. Since an established osteoporotic fracture strongly indicates an increased risk of further fractures, secondary prevention is then needed and intended to prevent new fractures from occurring.1

For primary prevention, multidisciplinary approaches involving patient education, lifestyle modification, fall prevention, appropriate medical treatment based on the guidelines, and adherence to this treatment are important to reduce the rate of fragility fractures and the growing burden of osteoporotic fractures in society. When a fragility fracture occurs, adequate procedures for stabilization according to the location of the fracture are necessary. Subsequent medical care for secondary prevention should be started and aim to attain optimal functional recovery, improve the quality of life after the fracture, and reduce the risk of future fractures.

Among the common types of osteoporotic fractures, hip fractures are the most serious and are easily associated with major morbidity, loss of independence, and even mortality.2,3 Furthermore, patients may experience a second hip fracture, especially within the first year after a first hip fracture.4 Therefore, it is essential to provide further pharmacotherapy after a surgical intervention to lower the risk of subsequent fracture. Vertebral fractures are also associated with a high risk of subsequent new fracture and morbidity. It is essential to identify vertebral fractures, even asymptomatic ones, as they increase the likelihood of new vertebral fractures by at least 4-fold. Compared with hip and vertebral fractures, distal radius fractures have no impact on mortality rates and are associated with a lower risk of recurrent fracture. However, the risk of osteoporotic fractures is higher than in those who have no previous wrist fracture; therefore, patients with osteoporotic wrist fractures should be considered as candidates for preventive measures. Unfortunately, although several studies have strongly indicated the increased risk for further fractures, many patients still do not undergo adequate investigation and receive any treatment for their underlying osteoporosis. Since fragility fracture care is often the first opportunity for patients to be treated for osteoporosis, routine assessments including history taking and physical examination, bone density measurement with dual-energy x-ray absorptiometry scans, and laboratory tests are necessary so that further treatment is optimal to prevent subsequent fractures.

A coordinated treatment program should be provided for osteoporosis patients with a fragility fracture. The therapeutic options to reduce the risk of subsequent fracture include calcium and vitamin D supplements and antiosteoporotic pharmacological treatment. Several classes of antiosteoporotic drugs are currently used, including bisphosphonates, calcitonin, estrogens and/or hormone therapy, raloxifene, denosumab, strontium ranelate, and recombinant parathyroid hormone (teriparatide). There are also guidelines for choosing pharmacological agents for primary and secondary prevention of osteoporotic fractures.5 Bisphosphonates, administered both orally or via intravenous infusion, are currently used as first-line treatment for osteoporosis and are of proven benefit in the prevention of fragility fractures. Teriparatide is recommended as an alternative treatment option for the secondary prevention of fragility fractures in patients who have contraindications or are intolerant to bisphosphonates. Strontium ranelate is another option with a new mode of action, which can be used for primary or secondary prevention. When choosing a pharmacological agent, the therapeutic decision should be based on a balance between the benefits and risks of each treatment for each particular patient and the location of the facture. Therapeutic agents found to decrease vertebral, hip, and other nonvertebral fractures should be considered preferentially over those that only have efficacy against vertebral fractures.

A multidisciplinary approach and coordinator-based program is important to improve postfracture osteoporosis care. Physicians and all health care professionals should cooperate together and follow the practice guidelines to give patients optimal care. Besides, willingness-to-participate and compliance with osteoporosis treatment are also very important. Educating patients and their families on the consequences and treatments for osteoporosis may help to improve the prevention of fractures and reduce its burden on society.


References
1. British Orthopaedic Association. The care of the patient with fragility fracture. London, UK: BOA-BGS; 2007.
2. Sweet MG, Sweet JM, Jeremiah MP, Galazka SS. Diagnosis and treatment of osteoporosis. Am Fam Physic. 2009;79(3):193-200.
3. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359(9319):1761-1767.
4. Nymark T, Lauritsen JM, Ovesen O, Röck ND, Jeune B. Short time-frame from first to second hip fracture in the Funen county hip fracture study. Osteoporos Int. 2006;17(9):1353-1357.
5. National Institute for Health and Care Excellence. Alendronate, etidronate, risedronate, raloxifene, strontium, ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. London, UK: National Institute for Health and Care Excellence; 2008.

6.D. Grigorie, Romania

Daniel GRIGORIE, MD, PhD
Associate Professor of Endocrinology
National Institute of Endocrinology C. I. Parhon
Carol Davila University of Medicine
Bucharest, ROMANIA
(e-mail: grigorie_d@yahoo.com)



Osteoporosis is a problem of bone fragility and fractures, and reducing the individual risk of fracture is the cornerstone of osteoporosis management. There may be some differences between primary and secondary prevention of fractures, albeit in principle all therapeutic agents have both indications and lifestyle recommendations are the same. Nevertheless, several points should be made: (i) After a fracture is sustained, several issues should be addressed: the need for fall prevention services, a review of the medications taken for compliance or alternatives, correction of vitamin D insufficiency, and an investigation into possible secondary causes. (ii) There is good evidence that prevention of the first fracture can be achieved with bisphosphonates, strontium ranelate, denosumab, and raloxifene, though there are some differences in their efficacy.

Most clinical trials have looked at vertebral fractures as the first fractures to prevent, as they are at the start of the fragility fracture cycle. In women without prevalent vertebral fractures treated with alendronate there was no significant decrease in clinical fractures in the overall population, but the reduction was significant in one-third of patients that had a baseline hip bone mineral density (BMD) T-score lower than –2.5 SD.12

Strontium ranelate reduces the risk of vertebral fracture in women with osteopenia and osteoporosis without vertebral fractures. A 41% reduction in the risk of vertebral fractures was seen in women with lumbar spine osteopenia and a 52% reduction was observed in women with osteopenia at both sites.3 The efficacy of strontium ranelate appears independent of the level of fracture risk assessed by FRAX® (Fracture Risk Assessment tool),4 as is also the case for raloxifene.5 There is no available evidence for teriparatide in patients without prevalent fractures.

Treatment of severe osteoporosis
Severe osteoporosis is a special issue as it affects the patients with the highest risk of fracture, and therefore, it is both ethical and cost-efficient to treat them as a priority. Currently, according to WHO criteria, the diagnosis of osteoporosis is based on BMD T scores that are ≤–2.5 SD at the spine or hip. Limiting the clinical diagnosis of osteoporosis solely to a T-score– based criterion creates uncertainty about the use of the term osteoporosis to diagnose older women and men who have T-scores >–2.5 SD, but either have already sustained low trauma fractures or are recognized as having a high fracture risk based on absolute fracture risk calculations using FRAX® or other algorithms. Currently, only few trials have specifically addressed very-high-risk populations, as is the case for alendronate, risedronate, zoledronate, and denosumab (the latter two in mixed groups of patients with or without prevalent vertebral fractures), which have shown a significant decrease in the risk of vertebral, nonvertebral, and hip fractures. Intravenous zoledronic acid has also been shown to decrease the risk of clinical fracture and mortality when given shortly after a first hip fracture.6 Teriparatide also reduces the risk of vertebral and nonvertebral fracture in patients with prevalent fractures. For ibandronate, an effect on nonvertebral fractures was only demonstrated in a post-hoc analysis of women with a baseline BMD T-score below –3 SD.7 With strontium ranelate, studies conducted up to 5 years have shown fracture efficacy at spinal, nonvertebral, and hip sites in patients with a very high risk of fracture, whatever the definition used: very low BMD, irrespective of the number of prevalent fractures, high FRAX®-based probabilities, frailty, and the oldest old (>80 years).5



References
1. Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998;280:2077-2082.
2. Reginster JY, Adami S, Lakatos P, et al. Efficacy and tolerability of once-monthly oral ibandronate in postmenopausal osteoporosis: 2 year results from the MOBILE study. Ann Rheum Dis. 2006;65:654-661.
3. Seeman E, Devogelaer JP, Lorenc R, et al. Strontium ranelate reduces the risk of vertebral fractures in patients with osteopenia. J Bone Miner Res. 2004;23: 433-438.
4. Kanis JA, Johansson H, Oden A, McCloskey EV. A meta-analysis of the effect of strontium ranelate on the risk of vertebral and non-vertebral fracture in postmenopausal osteoporosis and the interaction with FRAX®. Osteoporos Int. 2011; 22:2347-2355.
5. Kanis JA, McCloskey EV, Johansson H. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24:23-57.
6. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. New Engl J Med. 2007;357:1-11.
7. Harris ST, Blumentals WA, Miller PD. Ibandronate and the risk of non-vertebral and clinical fractures in women with postmenopausal osteoporosis: results of a meta-analysis of phase III studies. Curr Med Res Opin. 2008;24:237-245.

7. J. Li-Yu, Philippine

Julie LI-YU, MD, FPRA, MSPH
University of Santo Tomas Hospital
España
Manila, PHILIPPINES
(e-mail: julietanliyu@gmail.com)



Osteoporosis is a worldwide preventable metabolic bone disease that afflicts millions of postmenopausal women and should never be regarded as part of the physiological process of aging. Though diagnosis is confirmed based on the World Health Organization criteria for bone density using dual-energy x-ray absorptiometry (DXA), it is currently recommended that screening for osteoporosis be performed in all postmenopausal women ≥years of age and in women <65 years of age whose 10-year fracture risk is equal to or exceeds that of a 65-year-old white woman without additional risk factors. However, there is insufficient evidence to give recommendations to screen men without previous known fractures or secondary causes of osteoporosis.1

From a public health standpoint, primary prevention is the very essence of the social responsibility of medical practitioners to help circumvent diseases like osteoporosis. Primary preventive measures for osteoporosis are considered successful when fragility fractures are avoided or even proven to have lessened. This is considered as the most cost-effective way to deliver health care. In osteoporosis prevention, one needs to focus on educating the public on the importance of well-balanced nutrition, sufficient calcium and vitamin D intake, and appropriate age-specific physical activity, which should be started early in childhood in order to achieve high-quality peak bone mass. In women past the menopause and elderly men, preventive measures to maintain bone mass that are suited to their health status should, likewise, be encouraged.2 The use of pharmacological agents as part of a primary prevention strategy, especially in high-risk individuals, has been studied extensively in some countries based on pharmacoeconomic models of therapy. On the other hand, secondary preventive measures are needed to identify and address modifiable risk factors or preclinical disease in those whose condition is not clinically apparent. Since most patients with osteoporosis are asymptomatic, case-finding strategies in the presence of clinical risk factors are considered vital in halting the progression of a disease that leads to fragility fractures that will surely affect the quality of life of patients.

Measures to prevent secondary fractures remain a challenge globally. The majority of patients who suffer from fractures still fail to receive the appropriate secondary preventive care they need.3-5 There are effective treatments suited to the various patient clinical profiles, but their availability in a specific country is subject to the approval of that country’s regulatory agency. Treatments that are tailored to the needs of patients as well as the benefit-risk ratio of initiating therapy should always be considered. Other strategies include national health programs, such as fracture liaison services,6 which are intended to close the care gap and were found to be effective in various countries in providing secondary preventive care to patients with prevalent fractures.

Finally, whatever the plan of action taken by clinicians and health policy makers in the interest of patients and at-risk individuals, the ultimate goal is to reduce the burden of fragility fractures, but not to over-treat them, keeping in mind the patients who will most benefit from pharmacological therapies, irrespective of whether the purpose is primary or secondary prevention.


References
1. US Preventive Services Task Force. Screening for osteoporosis: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2011;154: 356-364.
2. Orimo H, Nakamura T, Hosoi T, Iki M, Uenishi K, Endo N, et al. Japanese 2011 guidelines for prevention and treatment of osteoporosis – an executive summary. Arch Osteopros. 2012;7:3-20.
3. Fraser LA, Ioannidis G, Adachi JD, Pickard L, Kaiser SM, Prior J, et al. Fragility fractures and the osteoporosis care gap in women: the Canadian Multicentre Osteoporosis Study. Osteoporos Int. 2011;22:789-796.
4. Hagino H, Sawaguchi T, Endo N, Ito Y, Nakano T, Watanabe Y. The risk of a second hip fracture in patients after their first hip fracture. Calcif Tissue Int. 2012;90: 14-21.
5. Leslie WD, Giangregorio LM, Yogendran M, et al. A population based analysis of the post-fracture care gap 1996-2008: the situation is not improving. Osteoporos Int. 2012;23:1623-1629.
6. Mitchell PJ. Best practices in secondary fracture prevention: Fracture Liaison Services. Curr Osteoporos Rep. 2013;11:52-60.

8. M. O’Brien, Ireland

Moira O’BRIEN, FRCPI, FFSEM,
FFSEM (Hon UK), FECSS, FTCD
Professor Emeritus
President, Irish Osteoporosis Society
IRELAND
(e-mail: mobrien@tcd.ie)



Primary prevention should be for everybody, as only 15% of cases are diagnosed. Prevention of osteoporosis is now a priority in many countries.1 Primary prevention protects healthy people against the disease, and this should start in utero and continue throughout the life cycle.

It is therefore important to educate people about preventing osteoporosis, particularly those who have risk factors. If a person develops a low-trauma fracture or is diagnosed with either osteopenia or osteoporosis, he/she should be treated. Bones need normal sex hormones; regular, appropriate, weight-bearing exercise; and adequate intake of calories, vitamin D3, and calcium.

Childhood and teenage years are critical periods for developing a strong, healthy skeleton,2 especially pre-puberty. Exercise is most beneficial for additional bone mineral acquisition before menarche (ie, during the growth spurt) rather than after menarche.3 In Ireland, physical activity levels decline substantially during adolescence.4 The Irish Osteoporosis Society, (IOS) has developed an educational schools package for 12- to 18-year-olds and a children’s book for 7- to12-year-olds.

Low vitamin D3 status is widespread in Ireland; nearly half of postmenopausal women have low levels during the winter. In addition, 30% of teenage girls are actually deficient during the winter months. The Health Service Executive (HSE) has implemented a recommendation that all babies from 0 to 12 months should be supplemented with vitamin D3 as rickets is now back in Ireland. Moreover, low vitamin D Levels result in secondary hyperparathyroidism.

The IOS recommends that from birth and throughout life, everybody should take the recommended daily amounts of calcium and vitamin D3 (preferably through food) not only to help prevent osteoporosis, but to treat osteoporosis and for overall health.

Secondary prevention should be provided for:
◆ All patients at risk of further fractures.
◆ All patients who have a medical condition that puts them at high risk of developing osteoporosis and osteoporotic fractures.
◆ All patients who are put on a treatment that will cause a reduction in sex hormone levels, eg, total hysterectomy, chemotherapy and radiation, and aromatase inhibitors for breast or prostate cancer.
◆ Any medication that will result in bone loss, eg, corticosteroids or prolactin-raising medication.

All patients with a low-trauma fracture or those at risk of fractures should have a dual-energy x-ray absorptiometry (DXA) scan and a detailed questionnaire to help determine the cause(s). It is important to carry out hormonal and biochemical investigations and correct any abnormalities. A fracture is among the strongest risk factor for future fractures. All patients who have had a low-trauma fracture should be put on antiosteoporotic medication to help prevent further fractures.

The majority of patients with fragility fractures are not evaluated, diagnosed, or treated for osteoporosis. Fracture liaison services were originally funded by the pharmaceutical industry, despite the fact that they have proved to be the most effective method of preventing future fractures. In Ireland, only 7 hospitals have a fracture liaison service or a dedicated person in charge: either a fracture liaison nurse or a doctor in the orthopedic outpatients or fracture clinic. Some orthopedic surgeons take an active role in optimizing the care of the fragility fracture patient with the ultimate goal of preventing future fractures. In Ireland, 14 of the 16 adult trauma units currently participate in the National Hip Data Audit. Many preventive measures for osteoporosis have been shown to have strong or fair evidence for their validity in preventing fractures. It is necessary to provide people with different risks for osteoporosis with valid preventive measures that correspond to their risk profile. Finding and addressing the cause(s) of osteoporosis is essential for secondary prevention.


References
1. Kanis JA. Osteoporosis. Oxford, UK: Blackwell Science; 1994:4-36.
2. MacKelvie KJ, Khan KM, McKay HA. Br J Sports Med. 2002;36:250-257.
3. Heinonen A, Sievanen H, Kannus P, Oja P, Pasanen M, Vuori I. High-impact exercise and bones of growing girls: a 9-month controlled trial. Osteoporosis Int. 2000;11:1010-1017.
4. Nic Gabhainn S, Kelly C, Molcho M. HBSC Ireland 2006: National Report of the 2006 Health Behaviour in School-aged Children in Ireland. Dublin, Ireland: Department of Health;2007.

9. V. Povoroznyuk, Ukraine

Vladyslav POVOROZNYUK, MD, PhD
Professor of Medicine, President of the
Ukrainian Association of Osteoporosis
President of the Ukrainian Association of
Menopause, Andropause, and Bone and
Joint Diseases, Director of the Ukrainian
Scientific-Medical Centre for the Problems
of Osteoporosis, Head of the Department
of Clinical Physiology & Pathology of the
Locomotor Apparatus, D. F. Chebotarev
Institute of Gerontology, National Academy
of Medical Science (NAMS), Kiev, UKRAINE
(e-mail: roksolan@zeos.net)



The principal goals of primary prevention of osteoporosis at various stages (peak bone mass formation, the postmenopausal period in women, men aged over 50) include adequate dietary intake of calcium, vitamin D, and protein; consistent physical activity; reducing the risk of falls; and the cessation of bad habits. Secondary prevention is used in patients with osteoporosis and/or in those with a history of low-energy fractures.

Recommendations on the amount of calcium intake and required doses of vitamin D for osteoporotic patients lack unanimity. The new European guidance for the diagnosis and management of osteoporosis in postmenopausal women states that postmenopausal women should get at least 1000 mg of calcium and 800 IU of vitamin D daily,1 while according to the National Osteoporosis Foundation’s (NOF) 2013 Clinician’s guide to prevention and treatment of osteoporosis, men aged between 50 and 70 years need 1000 mg of calcium per day,2 and women aged over 51 years and men aged 71 years and older must get a daily calcium dose of 1200 mg. As osteoporosis is very often associated with vitamin D deficiency, serum levels of 25(OH)D should be closely monitored, especially in case of associated hip fractures. The target of therapy is to bring the levels of 25(OH)D up to 30 ng/mL (75 nmol/L), with a subsequent intake of vitamin D to maintain optimum levels, especially in osteoporotic patients.

Correction of a protein-poor diet in older patients with a recent hip fracture results in clinical improvement during the period of rehabilitation, with fewer complications and a shorter period of hospitalization. No less than 1g of protein per 1kg of body weight is required.

Regular weight-bearing (walking, jogging, TaiChi, etc) and muscle- strengthening exercise leads to the general improvement of health, muscle function, posture, balance, and prevention of falls in osteoporotic patients. The optimal amount of weight bearing exercise required to maintain a healthy bone state in osteoporotic patients is unclear; however, physical activity is an integral element of recovery after fragility fractures. Modifiable factors for falls prevention are no less significant and include: improving eyesight, restricting fall-promoting factors, avoiding medications that reduce alertness, etc.

The essential distinguishing feature of secondary prevention is its use of pharmacological drugs. An established fragility fracture is a precondition for starting a medication without any additional bone mineral density (BMD) assessment. Nowadays, BMD is considered as an important—but not exclusive— criterion for fracture risk assessment; thus, fractures might be associated with osteopenia or normal BMD parameters, requiring the use of FRAX® (Fracture Assessment Risk tool). However, no uniform criteria for the initiation of pharmacological treatment according to the FRAX® tool have been developed. NOF advises starting medication in case of clinical/ asymptomatic hip or vertebral fractures, osteoporosis established by dual-energy x-ray absorptiometry (DXA) at the lumbar spine or femoral neck, or osteopenia at the abovementioned sites with a 10-year probability of hip fracture >3% and a 10-year probability of major fragility fractures >20% according to FRAX®,2 while the EU guidance contains an agespecific approach to medical interventions.1

According to the EU guidance, in osteoporosis established by DXA, bisphosphonates, raloxifene, strontium ranelate, and denosumab were associated with a reduction in the risk of vertebral fractures, while strontium ranelate and denosumab were associated with a reduction in the risk of nonvertebral and hip fractures. In case of established osteoporosis, antiosteoporotic efficacy and prevention of the risk of vertebral and nonvertebral fractures were proved for bisphosphonates, teriparatide, strontium ranelate, and denosumab, while prevention of the risk of hip fractures was most prominent with alendronate, risedronate, and strontium ranelate. Strontium ranelate has been shown to have the best number-needed to- treat (NNT) parameters for the prevention of vertebral and hip fractures.


Reference
1. Kanis JA, McCloskey EV, Johansson H, et al; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24(1): 23-57.
2. National Osteoporosis Foundation. 2013 Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013. Available at: http://www.nof.org/files/nof/public/content/resource/913/files/ 580.pdf.

10. S. Rojanasthien, Thailand

Sattaya ROJANASTHIEN, MD
Associate Professor
Department of Orthopedics
Faculty of Medicine
Chiang Mai University
Chiang Mai, THAILAND
(e-mail: srojanas@gmail.com)



The prevention of osteoporotic fractures is an important public health intervention. This is particularly true for hip and clinical vertebral fractures, which are usually associated with a high mortality, morbidity, and financial burden. In Thailand, the 1-year all-cause mortality rate after a hip fracture was 18% (males, 31%; females, 16%), which was 8 times higher than that in the general population. The 10-year mortality rate was 68%. Male gender, age >70 years, and nonoperative treatment showed a high correlation with increased mortality.1 Between 1996 and 2006, the number and incidence of osteoporotic hip fractures in Thailand increased, reaching an average rate of 2% per year.2

Fragility fractures can result in limitations in activities of daily living, fear of falls, and sometimes chronic pain, all of which can seriously affect the quality of life (QOL). It was reported that 50% of women who sustain a hip fracture do not return to their usual daily activities, while 33% will require long-term care. Restoration of QOL after surgery and fracture healing can be attained by two objectives: to reestablish mobility and prevent future falls.

A multinational survey conducted in France, Germany, Italy, Spain, the UK, and New Zealand reported that only 10% of patients get a bone mineral density (BMD) measurement after surgical treatment of a fragility fracture. The presence of a fragility fracture is the strongest indicator of the risk of future fracture. In the USA, only 2% of patients with a femoral fracture receive in-hospital initiation of osteoporosis treatment.

In Thailand, osteoporosis is diagnosed in only 7% of post-hip fracture patients, and only 6% of the patients receive antiosteoporotic treatment within 3 months of a fracture.3 Several explanations have been proposed; a lack of awareness on the part of surgeons and a fear of delaying fracture healing are probably the leading causes.

Treatment with intravenous zoledronic acid after a hip fracture is associated with a 28% reduction in all-cause mortality (hazard ratio, 0.72; 95% confidence interval, 0.5-0.93).4 Strontium ranelate may improve fracture healing in osteoporotic patients. An observational study of four case reports demonstrated fracture consolidation after 3- to 4-months’ treatment with strontium ranelate in men and postmenopausal women who previously had pseudarthrosis.5

Preventing osteoporotic fractures can potentially reduce the major consequences of osteoporosis. Thus, not only is secondary prevention important, but so is primary prevention. A 10-mg daily dose of alendronate is effective for secondary (number needed to treat [NNT]=16) and primary (NNT=50) prevention of vertebral fractures in postmenopausal women. It is also effective for secondary prevention of nonvertebral fractures, including hip or wrist fractures (NNT=100), but it is not effective for primary prevention of nonvertebral fractures. Risedronate demonstrated a main benefit in the secondary prevention of most osteoporotic fractures. At a dose of 5 mg per day, statistically significant reductions in vertebral, nonvertebral, and hip fractures were observed (but not for wrist fractures).

Strontium ranelate was shown to have antifracture efficacy at spinal and nonvertebral sites in a wide range of patients, from osteopenia sufferers to women over the age of 80 years, including osteoporotic patients with or without a prior vertebral fracture. A reduction in hip fracture rates has also been shown in women over the age of 74 years with low bone density at the femoral neck.6


References
1. Vaseenon T, Luevitoonvechkij S, Wongtriratanachai P, Rojanasthien S. Long-term mortality after osteoporotic hip fracture in Chiang Mai, Thailand. J Clin Densitom. 2010;13:63-67.
2. Wongtriratanachai P, Luevitoonvechkij S, Songpatanasilp T, et al. Increasing Incidence of Hip Fracture in Chiang Mai, Thailand. J Clin Densitom. 2013;16:347- 352.
3. Rojanasthien S, Chiewchantanakit S, Vaseenon T. Diagnosis and treatment of osteoporosis following hip fracture in Chiang Mai University Hospital. J Med Assoc Thai. 2005;88:S65-S71.
4. Lyles KW, Colón-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C. Zoledronic acid and clinical fractures and mortality after hip fracture. New Engl J Med. 2007;357:1799-809.
5. Alegre DN, Ribeiro C, Sousa C, et al. Rheumatol Int. 2012;32:439-443.
6. Kanis JA, Burlet N, Cooper C, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2008; 19:399-428.

11. E. V. Rudenka, Belarus

Ema V. RUDENKA, MD, PhD
Scientific Research Laboratory
Belarusian Medical Academy of Postgraduate
Education
Minsk BELARUS
(e-mail: rudenka.ema@gmail.com)



My patients often ask me if it is possible to cure osteoporosis. And in each specific case I ponder what to answer, as every single case is unique. But I always start my conversation with a discussion on the prevention of osteoporosis. In general, in order to improve the health of the whole population, and of course to strengthen bone tissue, we should summon six well-known “doctors”: sun, water, sleep, exercise, diet, and a positive attitude. They are the ones that know their job. All we need is to motivate ourselves to change our lifestyle in order to improve our health.

It is highly probable that in the absence of genetic predispositions, the risk of onset of osteoporosis will be minimal in the future in those people who constantly follow the principles of a healthy way of life. But are there a lot of heroes among us? At this point, a visit to the doctor is required. And this means examinations, establishing a diagnosis, and making decisions.

When speaking about osteoporosis more specifically, we are talking about primary and secondary prevention of the consequences of osteoporosis. It is one thing if there are no fractures, and entirely another if an osteoporotic fracture has occurred. At the stage of primary prevention and diagnosed osteoporosis (which is possible only by means of dual-energy x-ray absorptiometry [DXA]), we are faced with a dilemma: is the risk of osteoporotic fracture high enough to administer medical therapy? In this situation our decision is more likely to depend on T-score, comorbidity, and the risk factors/patient age ratio.

Thanks to the efforts of the many experts who study osteoporosis, there is already a wealth of evidence regarding the positive influence of healthy eating and adequate doses of calcium and vitamin D on decreasing the risk of falls and fractures,1 improving muscle strength and movement coordination, as well as providing conditions that enhance the efficacy of the medical treatment of imbalances in bone metabolism.2 Nevertheless, for the primary prevention of osteoporosis I would give a leading role in training the patient because knowledge encourages adherence to the doctor’s recommendations, particularly for long-term drug therapy.3

When the osteoporotic process has been complicated by a fracture, secondary prevention is required. This usually complex set of actions includes the administration of medicines and is aimed at preventing recurrent fractures or instability of the metal construct used in the surgical treatment of fractures. BMD, risk factors, and even age play a lesser role; in this context, antiosteoporotic therapy can be administered if the fracture corresponds to the criteria of osteoporosis—ie, a fracture that occurred as a result of minimal trauma. In such patients, when examining x-rays of the zone of fracture, there is evidence of impaired bone mineralization. Fractures do not always happen in the zones subjected to DXA scanning; a literature review—and my own personal experience—has shown that some patients with fractures have a T-score above –2.0 SD, which is the only dominant risk factor in their history.4

I am very impressed by the expert opinion of the Belgian Bone Club regarding the organization of a set of measures for the secondary prevention of osteoporosis.5 These measures are integrated in multidisciplinary and multifactor nonpharmacological programs for the correction of osteoporosis and its consequences, and include many aspects that can be influenced to prevent fractures in elderly patients. Prevention of osteoporosis should therefore involve (i) the correction of osteoporosis risk factors, adequate doses of calcium and vitamin D, healthy nutrition, and—of course—falls prevention by personal physical mobilization, creating conditions that improve the quality of life, the use of personal protection equipment (prosthetic devices, hip protectors, etc), and controlling the doses of drugs that influence both bone tissue metabolism and fall frequency; and (ii) modern methods of surgical treatment of both acute fractures and their consequences.

In conclusion, combining complex nonpharmacological programs aimed at correcting osteoporosis and its consequences with antiosteoporotic drugs, significant involvement of the patient, and regular support by the doctor in charge can have fantastic results.


References
1. Michael F. Holick, Neil C. Binkley, Heike A. Bischoff-Ferrari et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
2. Bischoff-Ferrari, HA, Willett WC, Orav EJ, et al. A pooled analysis of vitamin D dose requirements for fracture prevention. N Engl J Med. 2012;367:40-49.
3. Kanda K, Puech M, Chen JS, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporosis Int. 2013;24:393-406.
4. Gourlay ML, Fine JP, Preisser JS, et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med. 2012;366:225-233.
5. Body JJ, Bergmann P, Boonen S, et al. Non-pharmacological management: a consensus of the Belgian Bone Club. Osteoporosis Int. 2011;22:2769-2788.

12. G. Singh, Malaysia

Gobinder SINGH, FRCS
Consultant Orthopaedic Surgeon
Pantai Medical Centre
Pantai Hospital Kuala Lumpur
Kuala Lumpur, MALAYSIA
(e-mail: gsjoints@gmail.com)



Primary prevention is understood to mean prevention of a (first) osteoporosis-related fracture, and secondary prevention is the prevention of a second fracture, after detection of a first osteoporotic fracture.1 Common drug treatments for osteoporosis include bisphosphonates, selective estrogen receptor modulators (SERMs), parathyroid hormone analogues (teriparatide), anti-RANKL monoclonal antibody (denosumab), and strontium ranelate.2 In all these treatments, the patient must be advised to have an adequate intake of vitamin D (800-1200 IU/day) and calcium (1000-1200 mg/ day),3 or be supplied with supplementation. In addition, hormone replacement therapy, as prescribed by gynecologists, has a limited but definite role in osteoporosis, but the risk benefit balance needs individual evaluation.4 All these drugs can be subdivided into antiresorptive treatments (bisphosphonates, denosumab, SERMs) and anabolic agents (teriparatide, strontium ranelate).

For osteoporosis picked up at screening by dual-energy x-ray absorptiometry (DXA) scanning or by using the FRAX® tool,5 the commonest drug treatment prescribed in primary prevention are antiresorptive agents, with alendronate (a bisphosphonate) currently being the most commonly prescribed drug. Worldwide, secondary osteoporosis prevention uses the same drugs.6

Many orthopedic surgeons are, however, wary of prolonged antiresorptive therapy, which can so dramatically reduce bone resorption that serum CTX levels can approach zero. The concern that these doctors have is that bone remodeling, with a balance between resorption by osteoclast activity and bone formation by osteoblasts is important in maintaining bone health and healing the microfractures that occur naturally during the activities of daily living (the “frozen bone” concept). Orthopedic surgeons have all seen the so-called “atypical fractures”— for example in the subtrochanteric femur—which occur in patients on prolonged antiresorptive therapy. During surgery, the bone seems very well mineralized, but is extra hard. These fractures are often treated with internal fixation with a variety of additional modalities such as bone grafting or the addition of bone morphogenic proteins, etc. Studies suggest that these fractures do heal, but the low energy nature of these fractures is worrying.6

Currently, antiresorptive therapy needs, in my opinion, to be used for short periods of 5 years or less, and not at all unless frank osteoporosis (as determined by a BMD DXA T-score of less than –2.5 SD) is present.

My own practice is to use anabolic agents for secondary prevention of osteoporosis, and especially in patients who suffer fractures while on antiresorptive therapy. The drug of choice is either parenteral teriparatide or oral strontium ranelate, with teriparatide usually used in severe osteoporosis for a short period, and strontium ranelate being used for ongoing therapy.

As a result of my own comfort level with the management of osteoporosis with these drugs, my preference for primary prevention has also moved to anabolic agents, with strontium ranelate usually being the drug of choice. In all cases, adequate calcium and vitamin D intake should be ensured.


References
1. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2008;19:399-428
2. International Osteoporosis Foundation. Treating osteoporosis. http://www.iofbone health.org/treating-osteoporosis. Accessed September 16, 2013
3. Body JJ, Bergmann P, Boonen S, et al. Evidenced-based guidelines for the pharmacological treatment of postmenopausal osteoporosis: a consensus document by the Belgian Bone Club. Osteoporos Int. 2010:21:1657-1680.
4. Vickers MR, MacLennan AH, Lawton B, et al. Main morbidities recorded in the women’s international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women. BMJ. 2007;335:239.
5. FRAX®. WHO Fracture Risk Assessment Tool. http://www.shef.ac.uk/FRAX/. Accessed Sept 16, 2013.
6. Body JJ. How to manage postmenopausal osteoporosis? Acta Clin Belg. 2011; 66:443-447.

13. B. Stolnicki, Brazil

Bernardo STOLNICKI, MD
Federal Hospital
Ipanema
Rio de Janeiro, BRAZIL
(e-mail: stolnick@hotmail.com)



The guidelines for treating osteoporosis do not differentiate between osteoporotic patients who have had a prior fracture and those who have not. They only recommend that patients with prior fractures should be treated. For example, the drugs recommended as first- and second- line are the same.

On the other hand, there are well-defined criteria for changing medication in case of treatment failure. The occurrence of one or more fractures during treatment is considered as treatment failure. However, there is no indication that these criteria may be used in patients with prior fractures without pre-treatment.

The site of the fracture makes a difference. A vertebral fracture increases the chance of another fracture 4-fold; while a fractured wrist increases it 2-fold. Some fracture liaison services (FLS) consider that the cost-benefit balance of starting secondary prevention after a fractured wrist is not positive. Others include this type of patient (which is what I usually do). Ankle fractures, in this respect, are comparable to wrist fractures. However, there are no questions in relation to fractures of the hip and proximal humerus. Recommendations for physical activity and rehabilitation are directly linked to the type of prior fracture and the possible limitations its sequelae can impose.

Prevention of falls is critical in both primary and secondary prevention, as is ruling out the causes of secondary osteoporosis. Long-term safety and effective antifracture drugs must be used and adequate calcium and vitamin D supplementation required. What must differ in our approach to a patient who has already had an osteoporotic low-trauma fracture compared with another who has had no fracture is basically our attitude. The historic low adherence to antiosteoporotic treatment, which in primary prevention is a problem, becomes a catastrophe in secondary prevention because of the high risk of new fractures. The use of oral bisphosphonates is associated with low adherence. In the case of generic alendronate (which is the most used), it is even more obvious and the fractures that occur as a result of this notorious noncompliance are not taken into account when evaluating this apparently cheaper drug.

One of the strategies recommended by the Committee of Scientific Advisors of the IOF (International Osteoporosis Foundation), when referring to treatment failure in osteoporosis, is to replace an oral drug by an injected drug. There is no doubt that this recommendation is given because injected drugs are used quarterly, semi-annually, or annually, which improves treatment adherence.

The new status quo (the new fracture) requires this type of intervention. However, adherence is still below the desired level. One of the reasons for this lies in the habit of reviewing patients only once per year. There is no other serious illness (and osteoporosis is a serious illness; osteoporosis with fractures even more so) for which the follow-up is only done on an annual basis. This is not the case, for example, for diabetes, arterial hypertension, or heart disease.

The routine in our FLS is that there is a visit every four months in the first year; in the following years, the review is every six months. At each visit blood samples are collected to assess total serum calcium and 25OH vitamin D.

Motivating patients is of the utmost importance. The results of bone densitometry, with their small positive variations, often discourage patients. However, adequate vitamin D replacement demonstrates encouraging and motivating results. Since the majority of fractures occur in the first two years following a fracture, maintaining motivation and adherence is crucial at least in this period.