From the Guidelines
The patient should be initiated on pharmacological treatment for osteoporosis, prioritizing anabolic agents as the first-line therapy due to their high fracture risk and presence of multiple vertebral compression fractures, as recommended by the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. The patient's profile, with a moderate 10-year fracture risk initially, has escalated to a high-risk category (>20%) due to the presence of multiple vertebral compression fractures, indicating a need for prompt intervention to prevent further skeletal deterioration and maintain functional independence. Key considerations in managing this patient include:
- Risk stratification based on FRAX 10-year probability and DXA t- or z-scores, which categorizes the patient as high risk 1
- The preference for anabolic agents as initial osteoporosis (OP) therapy in very high fracture risk patients, due to their superiority in vertebral fracture prevention compared to anti-resorptives 1
- The importance of shared decision-making with patients to ensure understanding of the need for sequential therapy after certain OP treatments, such as denosumab (DEN), romosozumab (ROM), and parathyroid hormone (PTH)/PTH-related protein (PTHrP) 1
- Supplementing treatment with calcium 1000-1200mg daily and vitamin D 800-1000 IU daily to support bone health 1 The treatment should be tailored to the patient's specific comorbidities, preferences, and characteristics, rather than following a rank-ordered approach to medication recommendations 1.
From the Research
Assessment of Fracture Risk
- The patient's 10-year absolute fracture risk is initially categorized as moderate (10-20%) based on age, gender, and femoral neck mineral density readings 2.
- However, considering the patient's history of multiple compression fractures to the spine, which are presumed to be insufficiency fractures, the 10-year absolute fracture risk increases to the high category (greater than 20%) 3.
Fracture Risk Assessment Tools
- The Fracture Risk Assessment Tool (FRAX) is a widely used instrument for calculating 10-year absolute fracture risk, taking into account multiple clinical risk factors, including bone mineral density, and country-specific fracture and mortality data 2, 3.
- A hybrid system that combines femoral neck and lumbar spine bone density measurements has been proposed as an alternative approach to fracture risk assessment, which may provide a more accurate estimate of fracture risk in certain patients 4.
Treatment Considerations
- The National Osteoporosis Foundation Clinician's Guide recommends treating patients with FRAX 10-year risk scores of ≥ 3% for hip fracture or ≥ 20% for major osteoporotic fracture to reduce their fracture risk 3.
- Combination therapies, such as bisphosphonates and vitamin D-hormone analogs, have been shown to be effective in reducing fracture risk in postmenopausal osteoporosis, although the optimal treatment approach may vary depending on individual patient characteristics 5, 6.