An estimated 55 percent of
Americans over age 50 (44 million individuals) currently have osteoporosis or
are at risk for the condition due to dangerously thinning bones
(osteopenia).1 Over 2 million fractures of the hip, wrist, or spine
were attributed to osteoporosis in 2005 ? a number that is expected to rise 50
percent within the next two decades. For individuals in the 65 to 74 age group,
the increase is projected to top 87 percent.2 The price tag for
direct medical care for osteoporotic fractures is also steep, approaching $15
billion annually3, but the cost in individual pain, disability, and
reduced quality of life can be immeasurable.2
Especially vulnerable are women over
50, who account for 80 percent of osteoporosis cases. Plummeting hormone levels
during the five to seven years following menopause can result in a 20 percent
loss of bone density during this period.1 Since early-stage bone
thinning produces no obvious symptoms, 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
Tracking intervention after a
fracture
Despite this evidence, many women do
not receive bone mineral density (BMD) testing or osteoporosis treatment in the
months following a fracture.3 In an effort to shed light on this
disparity, the National Committee for Quality Assurance (NCQA) reports the
percentage of women over age 67 who receive a BMD test or are prescribed
osteoporosis medication within six months following a fracture. Exceptions
include women who have had BMD testing within the last year or who already take
osteoporosis drugs.4
In order to receive a 4-star rating
from the Centers for Medicare & Medicaid Services (CMS), a health plan must
fulfill the above NCQA measure at least 60 percent of the time. However, only
four CMS contracts achieved this goal for 2012. The majority provided screening
and intervention to less than 24 percent of patients for whom it was
appropriate, earning only a 1- or 2-star rating.5
Treatment of osteoporosis and
osteopenia
The National Osteoporosis Foundation
(NOF) guidelines recommend that women age 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).6
A bisphosphonate drug is the primary
medication choice for most women. Multiple studies confirm the effectiveness of
bisphosphonates in preventing vertebral, non-vertebral, and hip fractures. The
drug alendronate, now 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 for use in women with early bone loss.
Additional medications are also
available, but the choice of drug ultimately depends on the individual
patient's risk profile and preference. When possible, physicians should
consider formulary options so members can maximize their health plan benefits.
For more information about coverage and precertification requirements for
treatment options, please refer to our medical policy website.
Select Accept and Go to Medical Policy Online, and then type
"osteoporosis" in the Search box.
To supplement the medication regimen,
physicians may wish to counsel their patients on the importance of diet and
exercise in maintaining bone health:
- Calcium.
All adults need at least 1,200 mg of calcium a day. Since people age 50 and
older often do not consume more than 600 to 700 mg in their daily diets,
calcium supplements are recommended.
- Vitamin D.
Vitamin D is equally important. The NOF advises regular daily intake of 800 to
1,000 IU of
vitamin D daily for most adults, but individuals who have
health conditions that limit vitamin D absorption may need as much as 2,000 IU
a day to maintain adequate levels. Following a fracture, patients should be
tested for vitamin D deficiency and treated with therapeutic doses of the
vitamin until blood levels reach a normal range.
- Exercise.
Since weight-bearing exercise is critical in preserving bone mass,
rehabilitation is often recommended following a fracture to help patients
resume activities of daily living and establish a regular exercise routine.
Improvement in strength and balance can also help prevent falls and future
fractures.
- Alcohol and
tobacco cessation. Physicians should discourage health habits that are
linked to bone loss, such as tobacco use and heavy alcohol consumption. Efforts
should be made to steer the patient to smoking cessation programs or other
suitable treatment options.8
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. In addition, 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, however, indicates that there is
no benefit to repeating scans within the first three years of
treatment.7
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.8 Patients may also benefit from health coaching to support
healthful diet, exercise, and lifestyle choices and assess ongoing fracture
risk.