Bisphosphonate therapy: When &lt;i&gt;not&lt;/i&gt; to monitor BMD

Stevermer, James; ,

PURLs

Bisphosphonate therapy: When not to monitor BMD

J Fam Pract. 2009 November;58(11):594-596

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References

1. Bell KL, Hayen A, Macaskill P, et al. Value of routine monitoring of bone mineral density after starting bisphosphonate treatment: secondary analysis of treatment data. BMJ. 2009;338:b2266.-

2. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726.-

3. MacLean C, Newberry S, et al. Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med. 2008;148:197-213.

4. Agency for Healthcare Research and Quality United States Preventive Services Task Force. Screening for osteoporosis in postmenopausal women. Available at: http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm . Accessed October 13, 2009.

5. Schousboe JT. Cost effectiveness of screen-and-treat strategies for low bone mineral density: how do we screen, who do we screen, and who do we treat? Appl Health Econ Health Policy. 2008;6:1-18.

6. Black DM, Nevitt MC, Cauley J, et al. Design of the fracture intervention trial. Osteopor Int. 2003;3(suppl 3):S29-S39.

7. Cummings S, Black D, Thompson D, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures. JAMA. 1998;280:2077-2082.

8. Cummings S, Palermo B, Browner W, et al. Monitoring osteoporosis therapy with bone densitometry: misleading changes and regression to the mean. Fracture Intervention Trial Research Group. JAMA. 2000;283:1318-1321.

9. AACE Osteoporosis Task Force American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition with selected updates for 2003. Endocr Pract. 2003;9:544-564.

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WHAT’S NEW: Now we know early testing is unnecessary

Not many studies are available to provide guidance about the interval between BMD measurements after starting a bisphosphonate. This study advises us that it is not necessary to recheck BMD for at least 3 years after starting treatment. Elimination of early repeat DXA testing could result in significant cost savings.

CAVEATS: Findings contradict usual recommendations

Physicians should be aware that the conclusion of this study is not in line with recommendations from a number of prominent organizations. The American Association of Clinical Endocrinology,⁹ the National Osteoporosis Foundation,¹⁰ and the North American Menopause Society¹¹ all recommend follow-up DXA testing in 1 or 2 years.

High-risk patient exception. The delay in repeat DXA testing may not be appropriate for patients at higher risk of bone density loss. However, a separate analysis of higher-risk groups was not done.

Finally, while the findings of Bell et al suggest that we should wait at least 3 years before retesting, it is still not clear whether there is any benefit to repeat DXA testing at any interval, given the nearly universal response rate. It is also possible that advances in DXA technology will reduce some of the variation in BMD results.

CHALLENGES TO IMPLEMENTATION: Anxious patients

Patients like Ms. K may ask their physicians to retest well before 3 years. Yet those who undergo scanning after a shorter interval may be discouraged by early results. Advising patients that the treatment is almost uniformly effective in increasing BMD should reassure them that sticking with treatment is worthwhile.

Acknowledgment

The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

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Bisphosphonate therapy: When not to monitor BMD

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