Osteoporosis, the deafening silent epidemic. (Editorial).

Osteoporosis is a silent epidemic. About 40% of postmenopausal Caucasian women are expected to sustain an osteoporotic fracture during their lifetime. The one-year mortality rate following an osteoporotic hip fracture is about 20%, which means that one in five of those who sustain an osteoporotic hip fracture is expected to die within one year of the fracture, a mortality rate equivalent to that of breast cancer. Worse still, of the survivors, about 40% are so disabled that they are unable to resume their daily activities. This means that only two patients out of five who sustain an osteoporotic hip fracture resume their daily activities. Although the exact statistics for non-Caucasian women are not available, they are not expected to be much better. The one-year mortality rate in men who sustain an osteoporotic hip fracture is in fact worse than that of women: it is estimated to range from 30% to 50%. A patient can be asymptomatic until fractures occur; osteoporosis is often referred to as the silent epidemi c, an epidemic with high mortality and morbidity risks.

Osteoporosis, however, no longer has to remain silent and no longer has to be an epidemic. Over the past few years, major progress has been made in the non-invasive diagnosis of osteoporosis. Using dual x-ray absorptiometry (DXA),it is now possible to diagnose osteoporosis accurately, reliably, and non-invasively (the patient lies on a padded table for a few minutes while a hip and the lumbar vertebrae are scanned). The exposure to radiation is minimal. DXAs and Osteoporosis Centers have proliferated and there are not too many areas where these diagnostic tools are not readily available. The Bone Mass Measurement Act (BMMA) passed by Congress in July 1998 mandates that Medicare reimburse for a DXA scan if the patient has one of the following 5 conditions: (1) estrogen deficiency and clinical risk factors for osteoporosis; (2) the patient is on one of the FDA approved medications to treat osteoporosis in order to monitor the patient's response; (3) the patient is on, or about to go on, corticosteroid therapy i n doses equivalent to 7.5 mg of prednisone for 3 or more months; (4) the patient has radiologic evidence suggestive of osteoporosis in an x-ray of the vertebrae; and (5) the patient has hyperparathy-roidism. It is interesting to note that the BMMA does not specify how the diagnosis of estrogen deficiency is to be made. This diagnosis therefore can be made on clinical grounds. The indications for bone mass measurements are quite liberal and most insurers have relaxed many of their restrictions on reimbursing for a DXA scan; perhaps they have realized the potential advantages of this test in terms of identifying (and treating) those who have osteoporosis or osteopenia and the cost-effectiveness of the test.

The World Health Organization and the National Osteoporosis Foundation have issued diagnostic and management guidelines based on the results of DXA scans. The International Society of Clinical Densitometry has further elucidated some of the guidelines and is about to publish a Position Paper. The treatment strategy should not be based solely on the result of a test but on the patient's overall condition. These guidelines, however, provide very explicit help to the clinician who is trying to formulate a treatment strategy for a particular patient.

The availability of medication that can alter the course of osteoporosis and significantly reduce the fracture risk has been the main impetus to sharpening the diagnostic tools available. It is sobering to remember that it was only in September 1995 that the first bisphosphonate (alendronate) was approved by the FDA for the treatment of osteoporosis. There is now very convincing evidence that both alendronate (Fosamax) and risedronate (Actonel) significantly reduce the risk of hip fractures in patients with osteoporosis. Also, other medications are now available to reduce the risk of fractures and more are about to become available.

In fact, the evidence that medications can reduce the fracture risk is so convincing that it is probably only a matter of time before the legal profession realizes the potential of suing clinicians for not treating their osteoporotic patients. Although this would be very unfortunate and repulsive to most clinicians, yet, is there any difference between not treating a patient with osteoporosis and not treating a patient with breast cancer? Although no one would condone the latter regrettably many clinicians are still not actively treating their patients with osteoporosis. The silent epidemic is becoming deafening.

Clinicians still tend to overlook osteoporosis and often elect not to find out whether or not their patients have osteoporosis. Worse still, they sometimes decide not to treat a patient with documented osteoporosis. This rationale is truly difficult to understand. There is no longer any reason for osteoporosis to be an epidemic or to be silent. We have the means to accurately diagnose osteoporosis with confidence, and more important, we do have the means to significantly reduce the risk of fracture. We cannot allow the status quo to continue much longer. The silent epidemic must be curtailed. We can do it, we should do it, and, I dare say, we must do it.

Osteoporosis remains such a major problem that we have elected to devote this month's Featured CME Topic to this disease and use it as an update to the detailed Special Featured CME published in the Journal in June 2001. Readers are encouraged to refer to the June 2001 issue for the Coding and Reimbursement article, the listing of Community Resources, and the Medication Update. These features are available online on the SMA web site at www.sma.org. The main purpose of this issue is to apprise our readers of recent developments in this area. We are including a transcript of lectures by Dr. Nelson Watts and Dr. Douglas A. Linville II at the Fifth Annual SMA Conference on Osteoporosis in Amelia Island, Florida, February 22-23, 2002.

Ronald C. Hamdy, MD, FRCP, FACP Editor