Volume 10 · Nº 1 Supl · Apr 2018
- Osteoporosis: Concept. Pathophysiology. Clinical. Epidemiology [2-4]
- Osteoporosis and Primary Care. How to assess the risk of fracture. Use of risk scales [5-8]
- Clinical practice guidelines concerning osteoporosis [9-12]
- Treatment of osteoporosis [13-17]
- Adherence as a problem in osteoporosis: Alendronate soluble as a solution [18-22]
- Self-assessment test [22-23]
Osteoporosis is the most common bone metabolic disease. It is generally defined as “systemic skeletal disease characterized by decreased bone strength with consequent increase in bone fragility and susceptibility to fractures”1. The essential elements of this definition are low bone mass and microarchitectural alteration, which distinguish osteoporosis from other bone diseases. The alteration of the microarchitecture is characterized by the loss, thinning and lack of connection between the bony trabeculae, together with a series of factors, such as alterations in the bone remodeling and the bone geometry itself, among others that have been grouped under the concept of bone quality2. On the whole, osteoporosis involves a deterioration of the structural integrity of the bone which favors skeletal fragility and causes increased risk of fractures (fx).
The World Health Organization (WHO) established an operational definition based on bone mineral density (BMD) determination in any skeletal region for white women. Thus, normal BMD values were established to those higher than -1 standard deviation (SD) in relation to the mean of young adults.
Normal (T-score > of -1); osteopenia BMD values between -1 and -2.5 SD (T-score between -1 and -2.5); osteoporosis BMD values lower than -2.5 SD (T-score below -2.5) and established osteoporosis when, together with the previous conditions, one or more osteoporotic fx is associated3.
It is important to consider that the WHO criteria should be used preferably to ascertain the epidemiology of osteoporosis and not to apply them in isolation or to indicate preventive and therapeutic measures. Although not perfect, the definition of osteoporosis according to BMD is valid, since there is a strong association between BMD and fracture risk. Prospective studies show that the decrease of a SD in BMD increases the risk of fracture between 50 and 160% (relative risk: 1.5-2.6)4.
Osteoporosis is a metabolic bone disease characterized by a low bone mass and a deterioration of the microstructure of the bone tissue that leads to an increase in bone fragility and consequently to an increased risk of fracture1. Its real incidence is difficult to calculate since it is a silent process until the appearance of the fracture. It is one of the most prevalent osteo-articular diseases in primary care consultations. Since in 1994 the World Health Organization defined the densitometric values of osteoporosis which have been widely used to identify the population susceptible to suffering a fragility fracture2. Currently, population screening strategies3 are not recommended to identify patients with osteoporosis. Rather, a precautionary search is suggested in those subjects with a high risk of fracture4. In addition, in recent years the role of the exclusive assessment of bone mass to estimate the risk of fracture in patients has been questioned. Identifying these patients at risk to direct the necessary diagnostic and therapeutic options is one of our most difficult and controversial tasks.
Clinical practice guidelines (CPG) are a useful tool in medical practice, because they help guide the doctor in making decisions regarding a certain disease, based on a series of recommendations from the most up-to-date evidence available, combined with the consensus opinion of a group of experts on the subject1.
CPGs not only provide knowledge and recommendations to the clinician in managing a specific ailment, but are also useful for the sustainability of health services, as costs soar in an increasingly aging and more technologically advanced society.
With CPG, heterogeneity in clinical practice is reduced, maintaining the balance between scientific evidence, economic efficiency and competent variability of the medical professional.
This is especially important in the case of osteoporosis. Patients often require multidisciplinary care, participating in different levels of care, so that it is necessary to try to achieve maximum homogeneity in the management of patients.
Despite being governed by a series of statements or recommendations, the CPGs do not have to limit the doctor’s autonomy, as they are usually not binding. That is, they may not be followed in certain cases, if the patient’s specific characteristics or conditions advise another action guideline. In other words, the CPG will not replace the clinical judgment of the doctor who treats the patient.
In short, CPGs aim to maintain the quality of care through the adequate use of available resources, avoiding clinical decisions that are not scientifically based and reducing the variability of the practice.
Fracture fractures are the only clinical complication of osteoporosis1-3. Therefore, treatment should be aimed at preventing the appearance of fractures, since they are associated with an increase in morbidity and mortality4,5. In this sense, the presence of fragility fractures is a cause for alarm and treatment needs to be established as early as possible. It is wrong to think that when we treat a fractured patient we have arrived late and that it is not cost-beneficial to start treatment, because, on the one hand, having suffered a fragility fracture is a risk factor for a new fracture and on the other hand, the establishment of treatment for osteoporosis not only reduces the risk of new fractures, but also decreases the mortality of patients who have suffered them5,6.
The decision regarding pharmacological treatment of osteoporosis should be based on three fundamental pillars: the proven anti-fracture effectiveness of the chosen drug, its safety that will condition patient tolerability and the adherence that ensures the therapy is maintained as long as necessary, presumably from the time of diagnosis.
Osteoporosis (OP) as a chronic disorder with a relatively long initial course and asymptomatic to its complications represents a major problem of individual health and public health due to the costs involved. In addition, the therapeutic regimens currently available are uncomfortable and, therefore, contribute to the patient’s low therapeutic adherence1. Adherence is defined as compliance with the exact prescription provided to the patient and extended over the time indicated. When treating a chronic disorder, nothing can be achieved in the long term without persistence. Factors that influence treatment adherence include the prescribing physician’s explanations, the characteristics of the disease and the patient’s attitudes, but also the therapeutic regimen.
Other authors have indicated that the factors that influence OP therapy adherence include the cost of medications, adverse effects, frequency of dosage, education about the disease, patient follow-up and participation in the treatment decisions2,3. As maintaining treatment adherence is fundamental, extensive follow-up studies report (9,851 postmenopausal women referred to 141 Italian centers for OP management) that, in general, 19.1% of patients discontinued the prescribed medication before attending re-evaluations of bone mass, more than half of them in the first 6 months. The interruption rate was significantly different among treatments. The most frequent reasons for interruption were side effects related to medications, insufficient motivation for treatment and fear of these side effects3. The best medication is ineffective if it is not taken as it should be and the benefits of the treatment are lost if the patient does not take the medication. We currently know that patients with gastrointestinal symptoms have less adherence to treatment and worse quality of life in relation to health than patients without gastrointestinal symptoms4.
1. Maintaining the right time a treatment is fundamental in any disease chronicle. The factors
that influence the adherence to the treatment of osteoporosis, they are at your discretion:
a. The explanations of the prescribing doctor
b. The characteristics of the disease
c. The patient’s attitudes, but also the therapeutic regimen applied
d. All of the above
2. Adherence to a certain treatment in a chronic disease such as osteoporosis can be improved
by the following different strategies, except one:
a. Order the treatment with explanations even in writing and severely penalize the breach
b. Facilitate the dosage of the drug with more friendly guidelines
c. Improve safety in the gastrointestinal area
d. Inform the patient of the increase in the fracture rate among people who they
abandon their treatments