Physicians' guidelines for osteoporosis

Wiser use of the bone mineral density test and hormone replacement therapy are two strategies physicians can employ to prevent and manage osteoporosis, according to new guidelines issued by the National Osteoporosis Foundation.

The guidelines, outlined in "The Physician's Guide to Prevention and Treatment of Osteoporosis," give specific recommendations for Caucasian women, who are at greatest risk for the disease and for whom most of the data exists.

The Washington-based foundation identified the bone mineral density test as the single most reliable tool for assessing bone strength and osteoporosis risk.

Women who are 65 or older, postmenopausal women who have one or more risk factors for osteoporotic fracture and all menopausal women who have a fracture are prime candidates for bone mineral density tests.

All postmenopausal women who present with vertebral or hip fractures - two of the most common osteoporosis fracture sites - should be considered for osteoporosis treatment.

Treatment may include hormone replacement therapy or estrogen replacement therapy.

Hormone replacement therapy can result in a 50% to 80% decrease in vertebral fractures and a 25% decrease in nonvertebral fractures with five years of use, according to the guide. Researchers have also predicted a 50% to 75% decrease in all fractures with 10 years of use, and potential benefits to other organ systems.

Based on its effectiveness in preventing osteoporosis, along with other potential benefits for postmenopausal health, hormone replacement therapy may provide the greatest benefit relative to cost, according to the guidelines.

Routine screening

"Osteoporosis is a 'silent' risk factor for fracture, just as hypertension is for stroke," said foundation president Robert Lindsay, M.D. "Prevention, detection and treatment of osteoporosis should be a mandate of primary care, and a routine part of physicals."

If that is the case, physicians and patients will need to make substantial improvements in communication about the disease.

According to a survey conducted for the UCLA Osteoporosis Center and sponsored by Novartis Pharmaceuticals Corp., most American women are ignorant of key facts about osteoporosis, and very few discuss the disease with their physicians.

More than 90% of 514 women surveyed, for example, did not know that the most common osteoporotic fracture is a compression fracture of the spine. One-third of the women surveyed did not know that spinal fracture was even a potential consequence of osteoporosis.

Other findings from the UCLA survey:

• Only 28% of women understood that among osteoporosis, breast cancer, heart disease, ovarian cancer and Alzheimer's disease, women over age 50 are most likely to get osteoporosis.

• Nearly half of women said they know only a little or nothing at all about the disease.

• Thirty-nine percent of women over age 45 said they never discuss osteoporosis with their physician, even though they are at increased risk for the disease.

A desire to improve diagnosis of osteoporosis among post-menopausal women was a driving force behind the National Osteoporosis Foundation's release of the guide.

According to a 1997 study cited by the foundation, only about 14% of American women with osteoporosis receive treatment. The survey also estimated that only 29% of women with osteoporosis are diagnosed.

In another cited study of 100 patients who were over the age of 60 and staying in a hospital rehabilitation unit, none of the patients were initially diagnosed with osteoporosis. But when they were screened for the disease, 78% of the women and 27% of the men were at significant risk for fracture.

Early diagnosis and prevention

The National Osteoporosis Foundation stressed the importance of early detection and prevention.

For example, the foundation recommends that all adults obtain at least 1,200 mg of calcium per day and 400 to 800 IU of vitamin D per day; engage in regular weight-bearing exercise; and avoid use of tobacco and alcohol.

"Early diagnosis is important because bone loss is progressive, and by the time fractures occur, the disease is advanced and the likelihood of further hip, spine or other fractures is great," said Conrad Johnson Jr., M.D., vice president of the foundation and chair of the guide's development committee. "Hip fractures are not only disabling, but can be life-threatening. Twenty percent of people die in the year following a hip fracture."

Physicians can obtain single copies of the guide, or its pocket-sized companion guide, free-of-charge by contacting the National Osteoporosis Foundation. Packets of 10 can also be obtained at additional charge ($15 for the full-sized guide, and $5 for the pocket-sized guide).

Single copies of a guide customized for patients are also available free-of-charge, or in packets of 10 for $5.

The National Osteoporosis Foundation can be reached at 1150 17th St. NW, Suite 500, Washington, D.C. 20036-4603, by Facsimile (202) 223-2237, or via the Internet at www.nof.org. PR