Monitoring
Aim of monitoring is to increase adherence to therapy and to verify response to therapy
Bone Mineral Density (BMD) Measurement
- Recommended every 1-3 years after initiation of therapy until findings are stable and every 2 years thereafter
- Central dual energy X-ray absorptiometry (DXA) of the spine or hip is the gold standard for serial BMD assessment
- Should be done every 2 years
- If spine, hip or both cannot be assessed, 33% radius site can be used
- Patient follow-up ideally should be done within the same facility using the same machine
- Age-, disease- and treatment-related BMD changes can be monitored using quantitative computed tomography (QCT) measurement of trabecular BMD
Bone Turnover Markers
- Bone resorption markers may be measured before starting therapy and 3 or 6 months after starting treatment
- Bone formation markers may be measured before starting therapy and 6 months later
- High levels of bone resorption markers are associated with an increased risk of osteoporotic fractures
- Resorption markers may be used for assessing fracture risk in selected patients when BMD and clinical risk factors are not sufficient to make treatment decisions
Vertebral Imaging
- Repeat vertebral imaging is indicated for patients with the following:
- Documented height loss
- Presence of vertebral pain
- Changes in posture
- Chest X-ray abnormalities
- Due for reevaluation of treatment with possible withdrawal of therapy
- Presence of vertebral fracture during off-treatment interval
- Postmenopausal women who have been taking oral bisphosphonates for >5 years or IV bisphosphonates for >3 years should be reassessed for presence of fractures prior to initiation and during therapy
- Bisphosphonate therapy can be continued beyond 3-5 years in patients ≥75 years old, on high-dose oral glucocorticoid treatment, with prior history of hip or vertebral fracture, or who sustained a low-trauma fracture during therapy
- If fractures occurred, treatment with bisphosphonates may be continued or may consider the use of other agents
- If fracture-free, assess BMD T-score or fracture risk
- If with hip BMD T-score of <-2.5 or with high fracture risk, consider continuing bisphosphonate therapy or may change into other alternative agents
- If with normal bone mass and still no fractures, may consider withholding treatment and advise patient to follow up for fracture risk assessment every 1.5-3 years
Specialist Referral
- Consider a referral to a specialist when:
- Multiple fragility fractures are experienced
- A non-major trauma fracture is sustained by a patient with normal BMD
- With a very low BMD (T-score < -3)
- Continued bone loss or recurrent fractures happen in a patient on therapy but has no clear causes of bone loss that are treatable
- Osteoporosis has uncommon features, is severe, or rare secondary conditions are present, eg hyperparathyroidism, increased prolactin
- A condition is present that makes management difficult, eg chronic kidney disease, malabsorption