A Hidden Disease: Underdiagnosis and Undertreatment

Diagnosing Osteoporosis: Risk Factors and Indications for Testing

Diagnostic Classifications

Treatment Guidelines

The Goals of Treatment

Nonpharmacologic Therapy

Pharmacologic Therapy

Comparing Therapies

Nonresponse to Antiresorptive Therapy

Case Studies in Osteoporosis

Stuart L. Silverman, MD, FACP, FACR
Activity Director
Director, Fibromyalgia Rehabilitation Program
Department of Physical Medicine
Attending Physician, Division of Rheumatology
Cedars-Sinai Medical Center
Clinical Professor of Medicine and Rheumatology
David Geffen School of Medicine at UCLA
Los Angeles, Calif.
Dr Silverman is on the Board of Directors of CompuMed, Inc.; is a consultant for Merck, Novartis, Procter & Gamble, Roche, and Wyeth; has done contracted research for Eli Lilly, Merck, Novartis, Procter & Gamble, Roche, and Wyeth; and is on the speaker's bureau for Eli Lilly, Merck, Procter & Gamble, and Roche.

E. Michael Lewiecki, MD, FACP
Osteoporosis Director
New Mexico Clinical Research & Osteoporosis Center
Albuquerque, N.M.
Dr Lewiecki is a consultant and/or on an advisory board or speaker's bureau for Amgen, Eli Lilly, GlaxoSmithKline, Merck, Novartis Pharmaceuticals Corporation, Procter & Gamble, Roche, sanofi-aventis, Servier, and Wyeth Pharmaceuticals; has done contracted research for Amgen, Eli Lilly, GlaxoSmithKline, Merck, Novartis, Pfizer Inc., Procter & Gamble, Roche, sanofi-aventis, and Wyeth; and is a shareholder of General Electric and Procter & Gamble.

Robin K. Dore, MD
Clinical Professor of Medicine
David Geffen School of Medicine at the University of California, Los Angeles
Los Angeles, Calif.
Private Practice
Anaheim, Calif.
Dr Dore is a consultant and/or on the speaker's bureau for Eli Lilly and Company, GlaxoSmithKline, Merck & Co., Inc., Procter & Gamble Company, and Roche, and has done contracted research for Eli Lilly, Merck, and Roche.

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Cedars-Sinai Medical Center and The Partnership for Medical Education.

Cedars-Sinai Medical Center designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CREDIT EXPIRES: September 30, 2008

This activity is designed for endocrinologists, family practitioners, internists, rheumatologists, orthopedists, obstetricians and gynecologists, and other health care professionals interested in reducing fracture risk in patients with osteoporosis and low bone mass.

Osteoporosis is a systemic disease characterized by skeletal fragility, which is caused by low bone mass and microarchitectural deterioration that leads to increased risk of fracture. In the United States, 10 million individuals have osteoporosis, and 34 million more have low bone density, which places them at increased risk for the disorder. Osteoporosis results in more than 1.5 million fractures annually—nearly 300,000 hip fractures and 700,000 vertebral fractures. Prevalence is increasing overwhelmingly as the population ages, and approximately 61 million Americans are expected to have osteoporosis or low bone density by 2020.

Osteoporosis can remain virtually invisible until a fracture occurs, illustrating the need for increased efforts in screening and early diagnosis in order to prevent the devastating consequences of fracture, including chronic pain, disability, depression, loss of independence, and increased mortality. An estimated 50% of women more than 50 years of age will have an osteoporosis-related fracture in their lifetime, as will 25% of men. One third of individuals with hip fractures are discharged to a nursing home within 1 year following fracture, and one in five patients dies within 1 year after sustaining an osteoporosis-related hip fracture.

Prior to fracture, diagnosis is established by documenting low bone mass through bone mineral density (BMD) testing via a dual-energy x-ray absorptiometry test. Newer methods of measuring bone strength such as ultrasound have also been introduced and may have potential benefit in assessing fracture risk. Despite advancements in BMD screening and clear guidelines on who should be screened, roughly 20% of the 7 million fractures that occur annually are due to low bone mass.

Available pharmacologic treatment options for individuals with osteoporosis include calcitonin, recombinant human parathyroid hormone, bisphosphonates, hormone replacement therapy, and selective estrogen receptor modulators. New research has demonstrated that combination therapy, using medications that slow bone resorption with medications that enhance bone formation, may provide complementary mechanisms of action to help improve overall bone mass and quality and further reduce the risk of fracture by up to 80%. Thus, when considering treatment, clinicians should consider the combined effects of antiresorptives and anabolic agents that not only increase bone mass but also improve bone quality.

• Implement the current guidelines on the screening and treatment of osteoporosis.

• Identify patients at risk for osteoporotic fractures using bone density testing and clinical risk factors.

• Develop individualized treatment plans for patients with varying degrees of risk for fracture.

Copyright © 2007 Elsevier Inc.