Posts Tagged ‘Vertebral Fracture’
Our goal is NO NEW FRACTURES. Therefore, Treat to Target means a FRAX score of <20% for “major osteoporotic” and <3% for hip fracture. Alternately, T-score of better than -1.5 if there are any fractures.
Antiresorptives do not substantially increase bone mass or BMD. While a 3-5% BMD improvement can be seen when a long term deficiency in calcium absorption is corrected, the function of an antiresorptive is to maintain current bone mass.
If you want to substantially increase bone mass, you must use an anabolic medication. We now have 2. Forteo (teriparatide) has been available for 15 years. Tymlos (abaloparatide) was approved late last spring, but has only achieved good coverage by a majority of insurance companies in the last month.
Both can be given for up to 24 months. Both must be followed by an antiresorptive to avoid loss of gains. Both will show continued improvement in BMD for up to 3 years after switching to an antiresorptive because calcium takes up to 3 years to fully accumulate in new bone matrix formed by an anabolic.
Both should NOT be given to anyone with open growth plates, Paget’s, radiation to bone, cancers which have or could spread to bone, elevated bone specific alkaline phosphatase other than from fracture healing, or pregnant or nursing women.
Tymlos is approved for postmenopausal women only. It does not stimulate bone turnover significantly and therefore shows faster BMD increase initially in the hip. It has not been tested for use after antiresorptives.
Forteo is approved for men and women with osteoporosis which is “age-related”, or from steroid use, or from idiopathic hypogonadism. Forteo significantly increases both osteoblast and osteoclast activity, thereby stimulating bone turnover, which is often suppressed after long-term antiresorptives. Forteo is the default treatment for ONJ and AFF.
If you are dealing with vertebral fractures on VFA, or really low BMD on DXA, or with multiple fragility fractures, you need an ANABOLIC FIRST, to decrease fracture risk. Then follow with antiresorptives to maintain a low enough fracture risk.
Remember, even these medications will fail without proper nutrition.
jay Ginther, MD
Treat to Target of NO NEW FRACTURES. How do we find that target? DXA >-2.5 is a start. Fragility fractures increase new fracture risk. FRAX adds many more risk factors to the calculation and TBS refines FRAX.
Vertebral Fracture Assessment (VFA) looks at the spine from the side and independently identifies additional fracture risk. This can be done on a DXA machine or by x-ray. A single vertebral compression fracture of 25% or more pre-empts DXA, BMD, and FRAX in diagnosing Clinical Osteoporosis and recommending treatment.
VFA should be done because the majority of vertebral compression fractures are first noticed by x-ray or DXA VFA imaging. If you do not personally view the images, be sure the radiologist specifically checked for vertebral deformities as described by Genant.
I recently published my retrospective review of 1259 sequential first time VFA patients in Endocrine Practice 2017:23:1375-8.
VFA identified many patients not identified as high fracture risk (Clinical Osteoporosis) by DXA or fragility fracture or height loss or kyphosis or FRAX.
We should consider including VFA in every first time Complete Bone Health Evaluation.
And how should we treat? Next time…
Jay Ginther, MD
Our goal is NO NEW FRACTURES. Cancellous (spongy, like the ends of the drumstick) bone should be a strong latticework of struts called trabeculi. Clinical Osteoporosis, an increased fracture risk, occurs when some of the struts disappear.
Trabecular Bone Score (TBS) evaluates the spongy bone in the DXA images of the vertebrae (spine) looking for irregularities. When TBS finds uneven bone mineral density within the spine DXA, that indicates a higher fracture risk, regardless of the total BMD.
Adding the TBS feature to a DXA machine allows the quality of bone in the spine to influence the FRAX score, just like the BMD in the femoral neck part of the hip influences the FRAX score. Adding TBS detects more patients at high fracture risk who should be treated to avoid fractures.
Diabetes increases a person’s fracture risk for any given DXA BMD or T-score. Controlled diabetes adds about the same risk as rheumatoid arthritis, so we usually check that box in FRAX. Uncontrolled diabetes is more serious requiring further adjustment to FRAX.
FRAX is pre-empted by a hip fracture. “Do not pass GO, do not collect $200, start a pharmaceutical” Vertebral (spine) Fracture is the same, but the majority of spine fractures are not noticed clinically. “Morphometric” (first noticed on x-ray) vertebral fractures count, but how to find them?
VFA next time
Jay Ginther, MD
Clinical Osteoporosis 2017, NOF and ISCD joint meeting had a different emphasis this year. Fracture Risk, rather than Bone Mineral Density (BMD) is now the key metric. Several speakers emphasizd the importance of VFA in making the diagnosis of Clinical Osteoporosis. This is something I have presented in poster exhibits 2015, 2016 and 2017. I am now mainstream!
“Treat to Target” was the big new message this year. We should set a target of decreased Fracture Risk for each patient and alter treatment until we reach it. This has been routine for years in diabetes, hypertension, cholesterol, etc. This is recognition that Osteoporosis is a chronic disease that we can control, but never cure, just like many others.
Take Control Naturally is the necessary first step, as I have outlined over the last few months. This is often sufficient for prevention and in mild disease.
Advanced Osteoporosis, especially after fragility fractures, or vertebral compression fractures seen on VFA, is usually beyond nutrition and exercise only. This will usually require medications to significantly reduce fracture risk.
The huge change is the recommendation to use an Anabolic medication first, to markedly reduce fracture risk, when BMD is very low or multiple fractures have already occured. Then follow up with an Antiresorptive to maintain a low fracture risk. Traditionally Medicare and other insurances have demanded we try Antiresorptives first to maintain bone as it is, even when multiple fractures have proven the bone to NOT be good enough at curent BMD.
We are entering a new age of Fracture Prevention!!
Jay Ginther, MD