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.