Metabolic Bone Pearls Save

TRANSCRIPT:

Hello, my name is Betsy Kirchner and I'm a nurse practitioner in the Department of Rheumatic and Immunologic Diseases at the Cleveland Clinic, where I have been employed for over 25 years. We're going to do a quick video today on tips and tricks related to metabolic bone disease. 

If you do metabolic bone disease full-time, you probably know all of these. But, if like me and many of my colleagues maybe 20-25-30% of your patients are metabolic bone, sometimes it's good to have these little reminders. So I did an informal poll of my colleagues, both where I work and around the country and said, what are these little things that have been helpful or that maybe you need to be reminded of from time to time because they aren't front of mind all the time? 

The first one that came up a couple times is the VFA: the vertebral fracture assessment. 

It is often overlooked or maybe forgotten about, but it is critical. Not every machine can do VFAs, even at the Cleveland Clinic. Not every machine is equipped for that in terms of software, but we're getting there. So if you have VFA available, remember to request it in your orders because we all know so many of the compression fractures are asymptomatic. Patients don’t know they have it, they're not going to tell you they have sore back, but if you do that VFA, you'll see it. And then of course we know that - if we know that they have a positive VFA, if a compression fracture is seen by the radiologist - then that changes the diagnostic classification, it changes the management, it changes almost everything. So consider dedicated spine radiography or VFAs with DEXA in high risk patients. 

Next thing that came up in my informal poll was the RA osteoporosis connection. 

We all know the patients on aromatase inhibitors, that's a red flag. Patients who've been on long-term steroids, that's a big red flag. But sometimes we forget that patients with rheumatoid arthritis have about double the fracture risk of patients without rheumatoid arthritis (ame age group), and that's mostly due to inflammation, mediated bone loss or glucocorticoid use. And then sometimes even just the reduced mobility that can come along with active RA. 

So what can we do about that? Well, disease activity control with DMARDs helps preserve bone health by getting rid of that inflammation. And then also it's more of a, just being aware, being aware that these patients require vigilant monitoring. They may require bone densities earlier than you would normally screen, that sort of thing, so we don't end up having to play catch up down the road with severe osteoporosis. We can hopefully prevent it or catch it very early. 

Okay, next. Fracture liaison services.

I hope you guys have these. They have been just amazing here where I practice. Basically patients go in through the emergency room or wherever with a fracture and then they're discharged and the fracture is well managed. They're getting follow-up for that (including physical therapy), but then the osteoporosis checks sort of falls between the cracks. These fracture liaison services capture those patients. They're comprehensive programs. They do screening, treatment, education. Usually there's physical therapy involved. And in some studies it has shown that these liaison services can increase medication initiation and adherence from 17% to 38%. An overall difference of over 20% just by having these in place and therefore reduce subsequent fracture rates. So if you don't have a fracture liaison service, consider maybe starting one if that interests you, and if you do have one, make sure you take advantage of it.

Next is something I've already touched on a little bit. Glucocorticoid induced osteoporosis. 

It requires proactive treatment. I think we all know that. What is interesting is that the ACR actually stratifies this risk. They strongly recommend osteoporosis treatment for patients at moderate, high or very high fracture risk, receiving glucocorticoids with oral bisphosphonates as the first line therapy obviously, unless there's some sort of contraindication to that. So the interesting thing here is the stratification. I think we all know that patients on glucocorticoids need extra attention to their bone health. But if you look at the 2022 guidelines (I'm not going to read them here), the risk stratification is different for adults less than 40 years old versus 40 or older. How you stratify that, what you can take and as your puzzle pieces there. We know that FRAX is not validated in patients less than 40 years old, so the risk stratification relies on different criteria. So take a peek at that. Look at what construes very high fracture risk versus high versus moderate. I love that for patients on glucocorticoids, there is no low risk. And if you go to those guidelines, you'll see all of this great information. 

What I will touch on here real quick, last thing, is that included in those guidelines are the FRAX adjustment for glucocorticoid dose. I am guilty of this. I do not always recall that you can use math to get a more accurate FRAX risk for patients who are on glucocorticoids. So here's what you: if the prednisone dose is greater than seven and a half milligrams a day, you multiply their 10 year risk of major osteoporotic fracture, that basic FRAX by 1.15 and you multiply the hip fracture risk by 1.2. This will not accurately estimate risk for very high doses of prednisone, but for that seven and a half milligram, 10, 15, 20 milligram per day, you can use that math to get a more accurate fracture risk assessment.

Two quick examples where one, the first one does not change the FRAX, but it's still more accurate. A 70-year-old man with PMR: FRAX is 12, hip FRAX is 1.5. He's on prednisone 10 milligrams a day. The plan is to taper to five milligrams over the next four to six weeks. So if you do that math, the adjusted FRAX goes from 12 to 13.8, still below the threshold to treat. The hip FRAX goes from 1.5 to 1.8. Again, still below the threshold to treat, but this is better information for what if we can't wean them off prednisone. What if something else happens? What if there's another risk factor? It's a more accurate FRAX. 

Last example: a 70-year-old woman with COPD. FRAX is 15, hip FRAX is 2.8. She's on prednisone seven and a half milligrams a day as well. But she's unable to taper for her pulmonary, because of comorbidities, whatever, she's going to be staying on this dose or close to this dose long term. The adjusted FRAX for her is 17.3, still below the threshold to treat. Her hip FRAX is 3.4: above the threshold to treat. Would we treat her anyway because she's on seven and a half milligrams of prednisone long-term? Yes, probably. However, this adjusted FRAX may be helpful in terms of what you're trying to get approved through insurance. And also, again, it's just a more accurate picture of what this patient's risk for fracture is. 

That is what I have for you today. For all things rheumatology, please visit RheumNow and I thank you for your attention.

Editor’s note: This transcript has been prepared from the original recording and may include transcription inaccuracies. Please rely on the video for the most complete and accurate information.