Elsevier

Joint Bone Spine

Volume 72, Issue 6, December 2005, Pages 562-566
Joint Bone Spine

Original Article
Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners

https://doi.org/10.1016/j.jbspin.2004.03.014Get rights and content

Abstract

A low-impact fracture in a postmenopausal woman should prompt investigations for osteoporosis followed, if needed, by appropriate treatment.

Objectives. – To evaluate the impact of information alerting general practitioners to the need for osteoporosis treatment in postmenopausal women with a recent history of peripheral fracture.

Methods. – We conducted a prospective 7-month follow-up study of 78 postmenopausal women, with a mean age of 81.5 years, admitted to the emergency department for peripheral fractures. Three months after the fracture, we sent a letter to the general practitioner of each patient emphasizing the probable contribution of osteoporosis to the fracture and the need for osteoporosis treatment. Six months after the fracture, we interviewed the patients by telephone, and one month later we mailed a questionnaire to those physicians who had not followed the treatment recommendation.

Results. – At emergency room admission, 9 patients were receiving treatment for osteoporosis (hormone replacement therapy in one patient and calcium and vitamin D supplementation in eight patients). Admission to a ward was required in 66 (85%) patients. No treatment for osteoporosis was given at discharge. Six months after discharge, seven patients reported recent initiation of calcium and vitamin D supplementation, and none reported other osteoporosis treatments. The response rate to the physician questionnaire mailed 7 months after discharge was 54% (n = 28); responses showed treatment of 11 additional patients, by calcium and vitamin D supplementation in six cases and by bisphosphonates with or without calcium and vitamin D supplementation in five cases. Treatment initiation rates were similar in patients younger and older than 80 years.

Conclusions. – Despite information of general practitioners about the need for osteoporosis treatment, such treatment was initiated in only 30.5% of patients. General practitioners may be reluctant to initiate osteoporosis treatment in patients who are very old or have multiple comorbidities.

Introduction

Osteoporosis is common, as shown by the 40% likelihood of experiencing an osteoporotic fracture after 50 years of age in Caucasian women [1]. Osteoporosis defined as a bone mineral density (BMD) T-score decrease of at least 2.5 standard deviations is present at the hip, spine or forearm in 30% of postmenopausal Caucasian women [2]. Bone absorptiometry can detect asymptomatic osteoporosis, thereby allowing treatment initiation before the occurrence of fractures. Unfortunately, absorptiometry is not widely available. The French agency for healthcare evaluation (ANAES) has issued recommendations for defining high-risk populations and selecting patients who require absorptiometry [3]. Nevertheless, a subset of patients with osteoporosis fails to meet these criteria and consequently escape detection. In addition, BMD is only one of several factors that influence bone strength. Microarchitectural alterations responsible for an increased fracture risk are not detected by absorptiometry. Thus, the diagnosis of osteoporosis is frequently missed until the first fracture occurs. The National Osteoporosis Foundation recommends routine investigations for osteoporosis in postmenopausal women with fractures, followed by treatment if appropriate [4]. Fracture sites associated with a very high likelihood of osteoporosis are the distal forearm, proximal femur, proximal humerus, pelvis and spine. However, all low-impact fractures should suggest osteoporosis, except at the digits, skull and cervical spine. Vertebral fractures at the thoracic and lumbar spine are highly suggestive of osteoporosis but are frequently asymptomatic and therefore undetected. Fractures of the distal radius occur earliest in the natural history of osteoporosis, and their incidence rises sharply after 50 years of age [1]; nevertheless, physicians tend to overlook the association between distal radial fractures and osteoporosis. Establishing the diagnosis of osteoporosis is crucial, as several drug classes are effective in preventing further osteoporotic fractures. In most studies, low-impact peripheral fractures rarely prompted investigations and treatment for osteoporosis [5], [6], [7], [8], [9], [10], [11], [12], [13], [14].

The objective of the present prospective study was to determine the rate of osteoporosis treatment initiation by general practitioners in postmenopausal women managed at the Clermont-Ferrand Teaching Hospital emergency room for peripheral fractures. The original feature of our study is that we sent the general practitioners a standard letter emphasizing the need for considering and treating osteoporosis in postmenopausal women with peripheral fractures.

Section snippets

Patients

We included consecutive postmenopausal women managed at the Surgical Emergency Department of the Clermont-Ferrand Teaching Hospital between July 1 and September 30, 2000, for peripheral fractures related to minimal trauma (fall from the standing position at the most). Patients with vertebral fractures were excluded.

Methods

At emergency room admission, the following information was recorded on a standardized form: age, time since menopause, body weight, history of hormone replacement therapy (HRT)

Study population

During the 3-month study period, 78 patients met our inclusion criteria and were entered prospectively into the study. Table 1 reports their main characteristics. Mean age was 81.5 years, with a range of 50–99 years. The fracture site was the femoral neck in nearly half the patients and the distal radius in about one fourth. Table 2 provides additional detail on fracture site distribution.

Patient follow-up

Of the 78 patients, 66 (85%) required transfer to a ward; among them, 47 were admitted to a surgical ward

Discussion

A low-impact fracture usually indicates bone loss. Among women with wrist fractures, most have osteopenia or osteoporosis at one or more of the sites typically used for BMD measurement (lumbar spine, hip and radius) [15]. Numerous studies found that a history of fracture at any site was associated with a 2-fold increase in the risk of further fractures at any site [16]. In addition, the association between a history of fracture and an increased risk of further fractures was independent from BMD

References (20)

  • M.A. Rodriguez-Martinez et al.

    Role of Ca (2+) and vitamin D in the prevention and treatment of osteoporosis

    Pharmacol Ther

    (2002)
  • P. Lips

    Epidemiology and predictors of fracture associated with osteoporosis

    Am J Med

    (1997)
  • J.A. Kanis et al.

    The diagnosis of osteoporosis

    J Bone Miner Res

    (1992)
  • L’ostéoporose chez les femmes ménopausées et chez les sujets traités par corticoïdes: méthodes diagnostiques et indications

    (Avril 2001)
  • Osteoporosis. Review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis

    Osteoporos Int

    (1998)
  • S.A. Khan et al.

    Osteoporosis follow-up after wrist fracture following minor trauma

    Arch Intern Med

    (2001)
  • M.J. Gardner et al.

    Improvement in the undertreatment of osteoporosis following hip fracture

    J Bone Joint Surg Am

    (2002)
  • K.B. Freedman et al.

    Treatment of osteoporosis: are physicians missing an opportunity?

    J Bone Surg Am

    (2000)
  • M.T. Cuddihy et al.

    Osteoporosis intervention following distal forearm fractures. A missed opportunity?

    Arch Intern Med

    (2002)
  • H. Castel et al.

    Awareness of osteoporosis and compliance with management guidelines in patients with newly diagnosed low-impact fractures

    Osteoporos Int

    (2001)
There are more references available in the full text version of this article.

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