Association of Bone Density Monitoring in Routine Clinical Practice With Anti-Osteoporosis Medication Use and Incident Fractures: A Matched Cohort Study

DXA Reporting Updates: 2023 Official Positions of the International Society for Clinical Densitometry

INTRODUCTION

Professional guidance and standards assist radiologic interpreters in generating high quality reports. Initially DXA reporting Official Positions were provided by the ISCD in 2003; however, as the field has progressed, some of the current recommendations require revision and updating. This manuscript details the research approach and provides updated DXA reporting guidance.

METHODS

Key Questions were proposed by ISCD established protocols and approved by the Position Development Conference Steering Committee. Literature related to each question was accumulated by searching PubMed, and existing guidelines from other organizations were extracted from websites. Modifications and additions to the ISCD Official Positions were determined by an expert panel after reviewing the Task Force proposals and position papers.

RESULTS

Since most DXA is now performed in radiology departments, an approach was endorsed that better aligns with standard radiologic reports. To achieve this, reporting elements were divided into required minimum or optional. Collectively, required components comprise a standard diagnostic report and are considered the minimum necessary to generate an acceptable report. Additional elements were retained and categorized as optional. These optional components were considered relevant but tailored to a consultative, clinically oriented report. Although this information is beneficial, not all interpreters have access to sufficient clinical information, or may not have the clinical expertise to expand beyond a diagnostic report. Consequently, these are not required for an acceptable report.

CONCLUSION

These updated ISCD positions conform with the DXA field's evolution over the past 20 years. Specifically, a basic diagnostic report better aligns with radiology standards, and additional elements (which are valued by treating clinicians) remain acceptable but are optional and not required. Additionally, reporting guidance for newer elements such as fracture risk assessment are incorporated. It is our expectation that these updated Official Positions will improve compliance with required standards and generate high quality DXA reports that are valuable to the recipient clinician and contribute to best patient care.

Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry

Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.

[Development of the new guidelines on osteoporosis : Methodological and content development]

Since 2018, the present S3 guideline Prophylaxis, Diagnosis and Therapy of Osteoporosis (AWMF 183-001) has been updated following a previous update of the underlying PICO questions (Population-Intervention-Comparison-Outcome questions) for a systematic literature search. The focus of the guideline update, in addition to updating the evidence supporting literature along with recommendations, was the development of a risk calculator for vertebral fractures and femoral neck fractures. This is essential for managing risk assessment because of the multitude of risk factors that contribute to fracture risk. This article considers the development of the guideline update methodologically and substantively, the latter by reflecting on the core themes of the guideline update.

Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance

Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making.

INTRODUCTION

In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation.

METHODS

A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework.

RESULTS

We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence.

CONCLUSIONS

We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.

EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Osteoporosis management

Fractures occur in about half of older White women, and almost a third of older White men. However, 80% of the older individuals who have fractures do not meet the bone density definition of osteoporosis, suggesting that this definition is not an appropriate threshold for offering treatment. Fracture risk can be estimated based on clinical risk factors with or without bone density. A combination of calculated risk, fracture history, and bone density is used in treatment decisions. Medications available for reducing fracture risk act either to inhibit bone resorption or to promote bone formation. Romosozumab is unique in that it has both activities. Bisphosphonates are the most widely used interventions because of their efficacy, safety, and low cost. Continuous use of oral bisphosphonates for >5 years increases the risk of atypical femoral fractures, so is usually punctuated with drug holidays of 6-24 months. Denosumab is a further potent anti-resorptive agent given as 6-monthly s.c. injections. It is comparable to the bisphosphonates in efficacy and safety but has a rapid offset of effect after discontinuation so must be followed by an alternative drug, usually a bisphosphonate. Teriparatide stimulates both bone formation and resorption, substantially increases spine density, and reduces vertebral and non-vertebral fracture rates, though data for hip fractures are scant. Treatment is usually limited to 18-24 months, followed by the transition to an anti-resorptive. Romosozumab is given as monthly s.c. injections for 1 year, followed by an anti-resorptive. This sequence prevents more fractures than anti-resorptive therapy alone. Because of cost, anabolic drugs are usually reserved for those at very high fracture risk. 25-hydroxyvitamin D levels should be maintained above 30 nmol/L, using supplements if sunlight exposure is limited. Calcium intake has little effect on bone density and fracture risk but should be maintained above 500 mg/day using dietary sources.

Diminishing Value from Multiple Serial Bone Densitometry in Women Receiving Antiresorptive Medication for Osteoporosis

CONTEXT

The value of serial bone mineral density (BMD) monitoring while on osteoporosis therapy is controversial.

OBJECTIVE

We determined the percentage of women classified as suboptimal responders to therapy with antiresorptive medications according to 2 definitions of serial BMD change.

METHODS

This was a cohort study using administrative databases at a single-payer government health system in Manitoba, Canada. Participants were postmenopausal women aged 40 years or older receiving antiresorptive medications and having 3 sequential BMD measures. Women stopping or switching therapies were excluded. The percentage of women whose spine or hip BMD decreased significantly during the first or second interval of monitoring by BMD was determined. Suboptimal responder status was defined as BMD decrease during both monitoring intervals or BMD decreased from baseline to final BMD.

RESULTS

There were 1369 women in the analytic cohort. Mean BMD monitoring intervals were 3.0 (0.8) and 3.2 (0.8) years. In the first interval, 3.2% and 6.5% of women had a decrease in spine or hip BMD; 8.0% and 16.9% had decreases in the second monitoring interval; but only 1.4% showed repeated losses in both intervals. Considering the entire treatment interval, only 3.2% and 7.4% showed BMD loss at spine or hip. Results may not apply to situations of poor adherence to antiresorptive medication or anabolic therapy use.

CONCLUSION

Among women highly adherent to antiresorptive therapy for osteoporosis, a very small percentage sustained BMD losses on repeated measures. The value of multiple serial BMD monitoring to detect persistent suboptimal responders should be questioned.

Patient Outcomes in the Years After a DXA-BMD Treatment Monitoring Test: Improved Medication Adherence in Some, But Too Little Too Late

The role of mid-treatment monitoring dual-energy X-ray absorptiometry-bone mineral density (DXA-BMD) for bisphosphonate-treated patients with osteoporosis remains unsettled. A common reason for such monitoring is to encourage ongoing medication adherence. We sought to determine if a DXA-BMD treatment monitoring test was associated with improved medication adherence and whether improved adherence after a DXA-BMD treatment monitoring test was associated with subsequent reduction in fracture rates. Using linked administrative databases within Manitoba, Canada, we performed a retrospective cohort study of women starting and continuing antiresorptive therapy in whom a mid-treatment DXA-BMD monitoring test was performed. From the provincial pharmacy database, we estimated medication adherence by calculating annual medication possession ratio (MPR) and determining the change in MPR with respect to change (stable/decrease) in the DXA-BMD monitoring test, in addition to fracture rates before and after the test. The cohort comprised 3418 women, 90.7% treated with oral bisphosphonate, with pharmacy data for the 3 years before and after the mid-treatment DXA-BMD. Median (interquartile range) MPR was 0.84 (0.49-0.99) in the year before DXA-BMD and 0.84 (0.48-0.99) in the year after DXA-BMD (p = 0.37). Among those whose DXA-BMD declined, MPR in the prior year was 0.54 (0.04-0.92) but improved to 0.70 (0.31-0.92) in the year after DXA-BMD (p < 0.001). Among those whose DXA-BMD monitoring test was stable/improved, the fracture rate before the monitoring DXA-BMD was 10.1 per 1000 person-years and in those whose DXA-BMD monitoring test showed a decrease, the rate was 23.7 per 1000 person-years (p < 0.001). Despite improved adherence in those with DXA-BMD decline, the post DXA-BMD fracture rate was 22.4 per 1000 person-years versus 12.9 per 1000 person-years in those who had stable DXA-BMD (p < 0.001). A mid-treatment DXA-BMD reassessment strategy may be useful to focus attention upon adherence, but for optimal fracture outcomes, treatment adherence should be specifically addressed at the commencement of therapy. © 2021 American Society for Bone and Mineral Research (ASBMR).

Bone Mineral Density: Clinical Relevance and Quantitative Assessment

Bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DXA) is an internationally accepted standard-of-care screening tool used to assess fragility-fracture risk. Society guidelines have recommended which populations may benefit from DXA screening and the use of the fracture risk assessment tool (FRAX) to guide decisions regarding pharmacologic treatment for osteoporosis. According to the U.S. National Osteoporosis Foundation guidelines, postmenopausal women and men at least 50 y old with osteopenic BMD warrant pharmacologic treatment if they have a FRAX-calculated 10-y probability of at least 3% for hip fracture or at least 20% for major osteoporotic fracture. Patients with osteoporosis defined by a clinical event, namely a fragility fracture, or with an osteoporotic BMD should also be treated. Patients who are treated for osteoporosis should be monitored regularly to track expected gains in BMD by serial DXA scans. With some drug therapies, BMD targets can be reached whereby further improvements in BMD are not associated with further reductions in fracture risk. Although reaching this target might suggest a stopping point for therapy, the reversibility of most treatments for osteoporosis, except for the bisphosphonates, has dampened enthusiasm for this approach. In the case of denosumab, it is now apparent that stopping therapy at any point can lead to an increase in multiple-fracture risk. For patients who do not respond to antiosteoporosis pharmacologic therapy with an improvement in BMD, or who have an incident fragility fracture on therapy, secondary causes of osteoporosis or non-compliance with medical therapy should be considered.

The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women

PURPOSE

To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium.

METHODS

The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts.

RESULTS

Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered.

CONCLUSION

BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.