Osteoporosis often goes undetected and untreated. Here’s how CU Anschutz doctors are changing that

For many years, older adult patients who fractured their hip typically spent most of their recovery time with orthopedic doctors, working to regain their strength and function. But for some of those patients, that care only addressed part of their health issue, explains Michael McDermott, MD, a national endocrinology expert in the University of Colorado Anschutz Department of Medicine.

“Often, the reason for the fracture was osteoporosis. Yet, people are usually diagnosed with fractures in settings where osteoporosis is not thought about,” says McDermott, a professor of medicine and clinical pharmacy.

McDermott, who helped create the University of Colorado Hospital (UCH) Metabolic Bone Disease Clinic in 1995, has spent much of his career researching and treating patients with osteoporosis, a type of metabolic bone disease where a person’s bones become so fragile that a minor fall can cause major damage. The condition, which is estimated to affect more than 200 million people globally and occurs most often in postmenopausal women, can have detrimental effects on a person’s quality of life. That’s why the Metabolic Bone Disease Clinical Program, which is part of the Division of Endocrinology, Metabolism, and Diabetes, is developing multidisciplinary methods of detecting osteoporosis earlier so patients can get help sooner.

“When a person develops fractures from osteoporosis, it significantly deteriorates their quality of life. These fractures can cause a loss of breathing capacity, loss of independence, and sometimes premature mortality — so the consequences are enormous,” he says. “Because it can be quite disabling, it’s really important to diagnose it as early as possible.” 

Who’s at risk?

Osteoporosis can affect people of any age, but it is a common condition among older adults because people start losing their bone density around the age of 50 and older. According to the Food and Drug Administration, there are an estimated 10 million Americans with osteoporosis, and more than 80% are women.

“Our bones, during our lifetime, are always remodeling, which means we remove old bone and form new bone throughout the skeleton,” McDermott says. “Osteoporosis affects far more women than men, and the reasons for that are because women’s peak bone mass in their 20s is not as high as men, and the bone loss women experience after menopause is much more rapid compared to men.”

There are several risk factors for osteoporosis. The first is genetics, because the amount of bone density a person acquires when they are growing up and how much they lose as an older adult is partly genetically determined, he explains.

Other lifestyle factors, however, also play a key role. A lack of calcium, phosphate, and vitamin D in a person’s diet can limit how much bone density a person accumulates — and it can expedite how much bone density they lose when they are older. Having a sedentary lifestyle, excessively consuming alcohol and caffeine, and smoking cigarettes substantially also negatively affect bone health. Some medications, such as certain steroids, can also increase a person’s risk.

“When we recognize those risk factors, we can target people for earlier screening and be more proactive in preventing osteoporosis,” he says. “And if they already have it, then we will apply evidence-based treatment approaches.”

There are two groups of medicines for osteoporosis — medications that decrease bone loss and medications that help build new bone. These medications are usually not prescribed together, but rather used in a sequence, though the best drug sequence for patients is still being researched.

“Although we have medications to help prevent fractures, a very important component is the lifestyle measures,” McDermott says.

Detecting osteoporosis

One of the key signs of osteoporosis is when a person experiences a “fragility fracture,” meaning they got a broken bone from a relatively minor incident, such as a fall from standing height.

“The common fragility fractures are fractures that affect the vertebrae, spine, hip, wrist, and pelvis. If someone has a fragility fracture, unless you find another cause for it, that establishes a diagnosis of osteoporosis,” McDermott says.

When he first started practicing medicine, osteoporosis was only diagnosed after a person had a fragility fracture — but now, doctors have a way to diagnose the condition before a fracture occurs by using bone densitometry testing. The program at CU Anschutz is unique because its testing is shared between two types of doctors — endocrinologists and radiologists.

“This testing is approved for some populations — like women at the time of menopause, older adult men, and people taking certain steroids — but it is not available for everyone,” he says. “One of our initiatives is to get approval for more proactive bone densitometry testing so we can prevent fractures.”

Why fragility fractures are a big deal

Fragility fractures can alter a person’s quality of life, especially when they occur in older adults, McDermott explains. Vertebral fractures, for example, can lead to a person losing their height, struggling to breathe, having a stooped posture, and experiencing chronic pain.

“It can cause significant disability,” he says.

If a person experiences a hip fracture, their risk of death may increase by roughly 20%, he adds. An estimated 50% of people who survive a hip fracture will have some level of permanent disability.

“Once a person has an osteoporosis fracture, the risk of having another fracture is five times higher,” he says. “The consequences of fractures are substantial in older people. Identifying people who are at risk of osteoporosis as early as possible is our best solution.”

Collaborating to treat osteoporosis sooner

At CU Anschutz, doctors are collaborating to ensure patients with osteoporosis are getting the care they need. A prime example is the Metabolic Bone Disease program’s fracture liaison service, a multidisciplinary model of care that helps ensure patients who likely have experienced a fracture due to osteoporosis are connected with the appropriate resources.

“The reason our fracture liaison service is so important is that osteoporosis often is not treated, even in patients with a recent fragility fracture,” says Micol Rothman, MD, clinical director of the Metabolic Bone Disease program and a professor of medicine and radiology. 

Established in 2017 in collaboration with the Ambulatory Health Promotion team, the fracture liaison service works by having the health promotion team review the cases of any patient aged 65 and older who receives primary care within the UCHealth system and was discharged in the past 30 days from UCH with a hip, spine, wrist, or other osteoporosis-related fracture.

For those patients, the team will schedule an appointment with the appropriate primary care provider and obtain labs and bone densitometry testing ahead of time. A clinical pharmacist also provides collaborative drug therapy input. The primary care provider will meet with the patient to talk specifically about osteoporosis therapy, and if the patient’s case is complex, endocrinologists will get involved to provide their expertise.

Often less than 20% of patients with hip fractures will receive anti-osteoporosis treatment, Rothman notes. Thanks to a collaboration with orthopedic doctors and hospitalists, this service has also established new frameworks to help ensure that patients hospitalized at UCH with a hip fracture will receive osteoporosis treatment started in-house, in collaboration with hospital medicine.

Over the years, the fracture liaison service has demonstrated success at improving patients’ health by helping more patients get bone densitometry testing and start receiving osteoporosis medication.

“Our team’s services are an important way to identify people with osteoporosis earlier,” McDermott says. “I believe we’re among the first in the country to offer such fracture liaison services, and that’s been a big advantage our team has put forth. I think these efforts will help prevent osteoporosis and fractures for patients in the future.”