Experts review diagnostic imaging, treatment options for osteoporosis

During the session Osteoporosis: From DXA to Drugs, Amanda Crawford, CRNP, CCD, and Saba Mohiuddin, PharmD, BCACP, discussed the latest advances in the management of osteoporosis, with a special focus on diagnostic imaging and pharmaceutical interventions.

The session, which was originally presented Monday, Nov. 8, can be viewed by registered meeting participants through March 11, 2022.

Crawford opened the session with a review of dual-energy X-ray absorptiometry (DXA) in the diagnosis of osteoporosis. DXA is currently the gold standard in epidemiologic and pharmaceutical trials to measure changes in bone mineral density, said Crawford, a nurse practitioner at the University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic.

When reading a DXA scan, Crawford said she uses the pneumonic PARED: P for positioning; A for artifacts; R for regions of interest; E for edge detection; and D for database. She provided several tips and tricks for the proper positioning and reading of vertebral and hip DXA scans.

“If you want to learn more about how to accurately read DXA scans, you can always get certification in bone densitometry,” she said. “There are certifications for doctors who read the DXA scans and the technologists who perform the DXA scans. This is very important. If you have technologists who are not trained in how to do DXA scans, you may be treating people who do or do not have osteoporosis.”

Dr. Mohiuddin, a pharmacist at the Cleveland Clinic, reviewed prescription and over-the-counter treatment options for osteoporosis. As far back as 2011, the National Academy of Medicine (formerly the Institutes of Medicine) published guidelines that recommended daily supplementation with calcium and vitamin D to prevent osteoporosis, she said.

“It’s important to note that we should encourage our patients to primarily get their vitamin intake through diet, but if they are not able to meet these daily recommendations, to supplement any calcium that is needed,” Dr. Mohiuddin said.

Pharmacologic options include antiresorptive agents and anabolic agents. For postmenopausal women, bisphosphonates are the primary first-line option, she said.

Bisphosphonates work by inhibiting osteoclast activity and binding to hydroxyapatite. They have been shown to reduce vertebral, nonvertebral, and hip fractures; ibandronate reduces vertebral fractures only. These oral medications should be taken separately from other medications and food by 30 to 60 minutes, and patients should sit upright for at least 15 to 20 minutes to reduce esophageal issues.

Clinicians should consider bisphosphonate drug holidays for all patients, she said. The main goal of these holidays is to prevent rare side effects like osteonecrosis of the jaw and atypical femur fracture. The need for a drug holiday should be assessed every three to five years, Dr. Mohiuddin said.

Another antiresorptive agent, denosumab, has been shown to reduce vertebral, nonvertebral, and hip fractures, and is given as a subcutaneous injection every six months. If discontinued, clinicians should explore alternative options for their patients.

Teriparatide/abaloparatide are PTH analogs that activate osteoblasts and increase calcium and phosphate absorption. They are administered as at-home daily subcutaneous injections.

“Both medications are very expensive and are primarily reserved for severe osteoporosis patients,” Dr. Mohiuddin said.

Romosozumab is the newest anabolic agent. It is administered as a monthly subcutaneous injection in the office setting. It has been shown to lower the risk of subsequent fracture in women with fragility fracture, but Dr. Mohiuddin said she “prefers to start patients on some of our more cost-effective options such as bisphosphonates.”

There is a higher cardiovascular risk with romosozumab and it should be avoided in patients who have experienced a recent cardiac event or have high cardiovascular risk, she added.

Raloxifene is a hormone replacement therapy, but it is not a first-line option for patients, she said.

Dr. Mohiuddin shared a treatment algorithm that classifies women by risk — either moderate to high risk or very high risk. For women at moderate to high risk for osteoporosis, bisphosphonates are a great first-line option, she said. For women at very high risk, anabolic agents are indicated.