( PDF ) Rev Osteoporos Metab Miner. 2011; 3 (2): 73-4

Carbonell Abella C
Médico de Familia – Centro de Salud Vía Roma – Barcelona

 

Osteoporosis (OP) is a highly prevalent chronic disease which constitutes a public health problem, with significant medical and socioeconomic repercussions due, respectively, to the morbid-mortality which it brings and the direct and indirect costs which it generates. It is expected that with demographic changes which are happening, and the aging of the population, if there is no immediate intervention in clinical practice, the number of patients who will suffer at least one fracture will become greater.<
This is a silent disease; there are often neither signs nor early symptoms which alert us to its presence until the fracture occurs. It is these fractures which give clinical importance to the disease: more than half of women and a third of men will experience osteoporotic fractures during the course of their lives.
Free to run its course, the disease follows a chronic and progressive path, in which the appearance of fractures increases notably the risk of new fractures in other places, with the consequent deterioration in the quality of life of the patient. However, we have an opportunity to modify the course of this disease, through preventative measures which help avoid the loss of bone mass and reduce the risk of fracture, and by the treatment of patients with OP with the same aim.
When a pathology reaches the magnitude of osteoporosis, an approach which involves all health professionals is essential. This includes doctors in primary health care, due to their accessibility, the continuity in their dealings with patients throughout their lives, and the general nature of their care.
The majority of patients with osteoporosis should have been attended to in primary care. In order for this to happen, the doctors need to have the knowledge, skills and diagnostic tools which allow the correct management of these patients. There will be certain circumstances in which it will be advisable to refer the patient to a specialist.
It is often difficult to know what is the most appropriate action to take. In part, this difficulty in management lies in the fact that, given the multidisciplinary approach, there is a range of guides to clinical practice and recommendations from different scientific societies. There is little or no doubt in relation to secondary prevention, which is to say that, no patient with an osteoporotic fracture should leave the surgery without an evaluation of the risk of new fractures and an adequate therapeutic plan, with or without the use of drugs. The great difficulty is in finding uniform criteria to be used at the time of treatment in primary care. Until very recently this was solely based on densitometric (DXA) T-score values; the approach currently recommended is to assess the densitometry and clinical risk factors jointly, evaluating the absolute risk of fracture in the following years. All these difficulties in obtaining uniform criteria for assessment, and for indications for treatment, are especially important in primary care, where the difficulty in accessing diagnostic tests (essentially bone densitometry) represents the greatest obstacle. Equally important is the fact that the cost of drugs for antiresorptive treatment has increased notably in our country. In this edition of the review, Martínez and his collaborators analyse how appropriate prescribing is in relation to the recommendations of the guide for the management of osteoporosis in primary care published by SEMFYC in 2002.
Currently, the appearance of the FRAX tool, and the better knowledge of osteoporosis and its various treatments require us to rethink whether to continue in this way, or whether it is necessary to modify the indications as to who to treat, over what period of time, with which drug, etc.
In recent years, different working groups have also carried out studies in this area. All describe populations which are quite similar in primary care clinics in different geographical areas, and similar age groups, around 65 years of age, with a prevalence of previous fracture of 20-25% and with a body mass index (BMI) also similar (above 26-27). However, the variation in terms of whether or not the prescription is appropriate to the recommendations is notable. The work of Martínez et al., observed a percentage of appropriate prescription of biphosphonates of 55%, with 30% in which it was not possible to determine, and 13.7% being inappropriate. They therefore conclude that in less than 15% of cases was the prescription considered to be inappropriate.
This percentage is much lower than the findings of other works carried out in this country with populations with similar characteristics. Arana Arri1 found that 26.8% of patients who did not have any risk factor in their history, did however, receive treatment. Of the women who had had a diagnostic test (60% of the total) 42% were inappropriately treated, either excessively or deficiently. And Amaya et al.2 concluded that the prescription was appropriate to the recommendations in only 25.4% of patients. In the publication by Terol3, 62% of treatments were not appropriate to the clinical practice guides, without differences between specialisms.
In the work of De Felipe4, carried out in 212 women treated with antiresorptive drugs, there was a record of densitometry in 73.1% of those treated, and only 51.8% complied with the criteria for treatment.
Finally, Zwart5 concludes that primary care doctors seldom comply with the guidelines from the guides, and more specifically, the SEMFYC guide for the diagnosis and treatment of osteoporosis. At the same level of appropriateness as Martínez is the work of Pérez6 which finds a high degree of appropriateness to the SEIOMM guide, both in primary care (71%) and in specialist care (78%), with no significant differences.
We believe the work of Martínez et al. to be highly pertinent, for us, once again, reflecting the necessity of uniform recommendations for our patients, independent of the environment and of the professional by whom they are treated, based on the best possible scientific evidence, both for the diagnosis, as well as for the indication of treatment and most appropriate therapeutic option at that particular time.
BIBLIOGRAPHY
1. Arana-Arri E Gutiérrez-Ibarluzea I, Gutiérrez Ibarzaba ML, Ortueta Chamorro P, Giménez Robredo A I, Sánchez Mata AM, et al. Análisis comparativo frente a la evidencia del manejo de la osteoporosis en una comarca de atención primaria. Aten Primaria 2008;40:549-54.
2. Amaya M, Gómez M, Martínez M y Lendínez J. Adecuación del tratamiento preventivo de fracturas osteoporóticas en mujeres posmenopáusicas. SEMERGEN – Medicina de Familia 2008;36:121-7.
3. Terol Moltó C, Quintana-Cerezal J, Santos-Albero MJ, Corell González M, Marcos Martínez P, Crespo Mateos AP. Análisis de la prescripción de antirresortivos en el tratamiento de la osteoporosis en Atención Primaria. Revista Valenciana de Medicina de Familia 2007;24:40.
4. De Felipe R, Cáceres C, Cimas M, Dávila G, Fernández S, Ruíz T. Características clínicas de los pacientes con tratamiento para la osteoporosis en un centro de Atención Primaria: ¿a quién tratamos en nuestras consultas? Aten Primaria 2010;42:559-63.
5. Zwart Salmerón M, Pradera Vilalta M, Solanas Saura P, Gonzalez Pastor C, Adalid Vilar C. Abordaje de la osteoporosis en un centro de Atención Primaria. Aten Primaria 2004;33:183-7.
6. Diez Pérez A, Guañabens Gay N, González Macías J, Jódar E, Muñoz Torres M, Fuster Jensen E. Adecuación del manejo clínico de la osteoporosis a las guías de la SEIOMM. Estudio OPINHO-PC. Rev Esp Enferm Metab Oseas 2008;17:59-65.