The role of risk communication in the care of osteoporosis

Patients' preferences for fracture risk communication: the Risk Communication in Osteoporosis (RICO) study

The RICO study indicated that most patients would like to receive information regarding their fracture risk but that only a small majority have actually received it. Patients globally preferred a visual presentation of fracture risk and were interested in an online tool showing the risk.

PURPOSE

The aim of the Risk Communication in Osteoporosis (RICO) study was to assess patients' preferences regarding fracture risk communication.

METHODS

To assess patients' preferences for fracture risk communication, structured interviews with women with osteoporosis or who were at risk for fracture were conducted in 11 sites around the world, namely in Argentina, Belgium, Canada at Hamilton and with participants from the Osteoporosis Canada Canadian Osteoporosis Patient Network (COPN), Japan, Mexico, Spain, the Netherlands, the UK, and the USA in California and Washington state. The interviews used to collect data were designed on the basis of a systematic review and a qualitative pilot study involving 26 participants at risk of fracture.

RESULTS

A total of 332 women (mean age 67.5 ± 8.0 years, 48% with a history of fracture) were included in the study. Although the participants considered it important to receive information about their fracture risk (mean importance of 6.2 ± 1.4 on a 7-point Likert scale), only 56% (i.e. 185/332) had already received such information. Globally, participants preferred a visual presentation with a traffic-light type of coloured graph of their FRAX® fracture risk probability, compared to a verbal or written presentation. Almost all participants considered it important to discuss their fracture risk and the consequences of fractures with their healthcare professionals in addition to receiving information in a printed format or access to an online website showing their fracture risk.

CONCLUSIONS

There is a significant communication gap between healthcare professionals and patients when discussing osteoporosis fracture risk. The RICO study provides insight into preferred approaches to rectify this communication gap.

Patient Perception on Osteoporosis in Korean Female Patients with Osteoporosis

BACKGROUND

Patient perception is a key element in improving compliance with medications for osteoporosis. This study evaluated the awareness, perception, sources of information, and knowledge of osteoporosis among Korean women with osteoporosis.

METHODS

A questionnaire survey was conducted from July 22, 2021 to 13 August 2021. Patients who were followed up in endocrinology (Endo), orthopedic surgery (OS), and gynecology (GY) were recruited (N=40, 40, and 20 in each group). Patients were allocated according to their age, as follows: 15, 15, and 10 patients in their 60s, 70s, and 80s for Endo and OS, and 10 and 10 patients in their 60s and 70s for GY. The questionnaire was composed of the following topics: patient journey to the hospital, drug-related issues, communication with medical doctors, patient knowledge, and sources of information about osteoporosis.

RESULTS

The results of medical check-ups were the most common reason for patient visits to the hospital for an initial diagnosis of osteoporosis (61%). A knowledge gap regarding mortality, refracture, and drug-induced osteoporosis was observed. Doctors were the most preferred and trustful source of information, while health-related TV shows were the second most common source of information. Patients with OS reported lower perceived severity and higher drug discontinuation, along with a higher proportion of fractures, as the initial reasons for hospital visits for osteoporosis.

CONCLUSIONS

Variations in perceptions according to the issue and group were identified. These should be considered during patient consultations to improve compliance with osteoporosis treatment.

The clinician's guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Effective communication regarding risk of fracture for individuals at risk of fragility fracture: a scoping review

Two scoping reviews were conducted to review recommendations and guidelines for communication regarding general health risk, and to investigate communication strategies regarding risk of fracture. Healthcare professionals are invited to apply these recommendations to optimize a patient-centered approach to reducing risk of fracture.

INTRODUCTION

To conduct a scoping review of the medical literature regarding recommendations and tools for effective communication between healthcare professionals and patients regarding general health risk and risk of fracture.

METHODS

The scoping review was divided into two parts to search for (1) studies presenting recommendations and guidelines for communication regarding general health risk; (2) studies investigating communication regarding risk of fracture for individuals at risk for fractures. Medline was searched in April 2020 to identify relevant studies.

RESULTS

The scoping review included 43 studies on communication with regard to general health risk and 25 studies about communication regarding risk of fracture. Recommendations for effective communication with regard to risk are presented. Communication of numeric data on risk should be adapted to the literacy and numeracy levels of the individual patient. Patient understanding of numerical data can be enhanced with appropriate use of visual aids (e.g., pie charts, icon arrays, bar charts, pictograms). The FRAX® tool is the most recommended and most used tool for assessing risk of fracture. Communication sent as individualized letters to patients following DXA scans has been studied, although patient understanding of their risk of fracture is often reported as low using this technique. Use of visual aids may improve patient understanding.

CONCLUSION

Healthcare professionals are encouraged to apply recommendations presented in this scoping review in their clinical practice. Patient understanding of risk of fracture should be confirmed by making sure that patients feel free to ask questions and express their concerns. This will contribute to an optimal patient-centered approach. Developing online tools to convert the probability of fracture into patient-friendly visual presentations could facilitate communication between healthcare professionals and patients about risk of fracture.

Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care.

METHODS

We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals.

RESULTS

While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ.

CONCLUSIONS

This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX_® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.

Understanding and communicating the benefits and risks of denosumab, raloxifene, and teriparatide for the treatment of osteoporosis

The number needed to treat is a valuable metric to determine the benefit of therapy, but it must be viewed against the respective number needed to harm. Denosumab and teriparatide (TPTD) have proven antifracture efficacy at vertebral and nonvertebral sites, whereas raloxifene has proven antifracture efficacy at the spine only. Denosumab use has been associated with a small, yet statistically significant, increased incidence of eczema and serious cellulitis. Raloxifene use has been associated with statistically significant increases in the risk of venous thromboembolism and possibly deadly stroke, although not an increase in total strokes. No significant, nontransient adverse events have been reported with TPTD use. When used for the treatment of postmenopausal osteoporosis, denosumab, raloxifene, and TPTD all generally have favorable risk-to-benefit profiles, but therapy-specific contraindications necessitate thoughtful consideration of all available clinical information and individualization of treatment decisions.

The impact of bone mineral density testing, fracture assessment, and osteoporosis education in men treated by androgen deprivation for prostate cancer: a pilot study

PURPOSE

Men receiving androgen deprivation therapy for prostate cancer have low knowledge of osteoporosis (OP) and engage in few healthy bone behaviors (HBBs). A multicomponent intervention was piloted in this population. Changes in OP knowledge, self-efficacy, health beliefs, and engagement in HBBs were evaluated.

METHODS

A pre-post pilot study was performed in a convenience sample of men recruited from the Princess Margaret Cancer Centre. Men were sent personalized letters explaining their dual x-ray absorptiometry (DXA) results and fracture risk assessment with an OP-related education booklet. Participants completed questionnaires assessing OP knowledge, self-efficacy, health beliefs, and current engagement in HBBs at baseline (T1) and 3 months post-intervention (T2). Paired t tests and McNemar's test were used to assess changes in outcomes.

RESULTS

A total of 148 men completed the study. There was an increase in OP knowledge (9.7 ± 4.3 to 11.4 ± 3.3, p < 0.0001) and feelings of susceptibility (16.5 ± 4.3 to 17.4 ± 4.7, p = 0.015), but a decrease in total self-efficacy (86.3 ± 22.9 to 81.0 ± 27.6, p = 0.007) from baseline to post-intervention. Men made appropriate changes in their overall daily calcium intake (p ≤ 0.001), and there was uptake of vitamin D supplementation from 44 % (n = 65) to 68 % (n = 99) (p < 0.0001). Men with bone loss (osteopenia or OP) had a greater change in susceptibility (1.9 ± 4.3 vs. -0.22 ± 4.2, p = 0.005) compared to men with normal bone density.

CONCLUSIONS

Our results provide preliminary evidence that a multicomponent intervention such as the one described can lead to increased knowledge and feelings of susceptibility regarding OP and can enhance uptake of some HBBs.

Safety and tolerability of denosumab for the treatment of postmenopausal osteoporosis

Denosumab is a fully human monoclonal antibody to receptor activator of nuclear factor kappa-B ligand (RANKL), a cytokine member of the tumor necrosis factor family that is the principal regulator of osteoclastic bone resorption. Postmenopausal osteoporosis (PMO) is a systemic skeletal disease associated with high levels of RANKL, resulting in a high rate of bone remodeling and an imbalance of bone resorption over bone formation. By inhibiting RANKL in women with PMO, denosumab reduces the rate of bone remodeling, thereby increasing bone mineral density, improving bone strength, and reducing the risk of fractures. In clinical trials of women with osteoporosis and low bone mineral density, denosumab has been well tolerated, with overall rates of adverse events and serious adverse events in women treated with denosumab similar to those receiving placebo. In the largest clinical trial of denosumab for the treatment of women with PMO, there was a significantly greater incidence of cellulitis reported as a serious adverse event, with no difference in the overall incidence of cellulitis, and a significantly lower incidence of the serious adverse event of concussions with denosumab compared with placebo. The evidence supports a favorable balance of benefits versus risks of denosumab for the treatment of PMO. Assessments of the long-term safety of denosumab are ongoing. Denosumab 60 mg subcutaneously every 6 months is an approved treatment for women with PMO who are at high risk for fracture.