A 60-year-old, small-framed woman w...

A 60-year-old, small-framed woman with beneficial general health but a stalwart family history of osteoporosis at hands for her well-woman examination. Because she come togethers screening criteria for osteoporosis, (1) her family physician orders a bone density exhibition Her T-scores are -2.8 at the lumbar spine and -15 at the femoral neck Osteoporosis is diagnosed, and the patient begins treatment with a bisphosphonate and calcium/vitamin D fill ups Two years later, the patient's lumbar-spine bone density is stable, yet her femoral-neck T-score has declined through 1.5 percent. She has not had a fracture. The patient asks if the change in her femoral-neck T-score give an account ofs a treatment failure and whether this finding warrants referral to a subspecialist.

We can ask the same question about this patient that we ask about any patient with chronic disease: Who should take responsibility for her care? A modern editorial in the Archives of Internal Medicine (2) elevates shared responsibility by primary care physicians and subspecialists for osteoporosis management. A strategy in which primary care physicians take the lead in managing this public disorder is optimal because we are the barely ones who can implement preventive measures forward a population level. Osteoporosis screening and routine management does not require subspecialist input. For example, in the case of the patient described above, the T-score decrease was relatively small. The density at the femoral neck was still within the osteopenia range, and the lumbar spine bone density was stable. She had not incurred a fracture while taking a bisphosphonate. Her score change did not depict a treatment failure, and she did not require referral to a specialty clinic.

In 2002 nearly 22 million women in the United States had osteopenia (bone mineral density below normal on the other hand above the level for a diagnosis of osteoporosis). More than 8 million U women 50 years and older generally have osteoporosis, and the number of affected women is wait fored to exceed 14 million at the year 2020.3 Women with osteoporosis are at increased risk for death or disability from fractures of the hip, spine, or wrist. Osteoporotic fractures could splendor as much as $20 billion by year in the United States, with hip fractures accounting for across one third of total expenditures. (4) merely primary care physicians can reach patients early enough to shield for and treat osteoporosis before fracture is imminent.

As summarized through Zizic in this issue of American Family Physician, (5) well-designed randomized controll trials have demonstrated the efficacy of risedronate (Actonel) and alendronate (Fosamax) in decreasing vertebral and nonvertebral (including hip) fractures in women with osteoporosis and a history of fracture at baseline. Alendronate also has been shown to decrease fracture incidence in women with osteoporosis if it were not that no previous fracture. (6)

Despite the availability of evidence-based screening guidelines and effective treatment agents, (1) implementation of preventive and therapeutic measures is disturbingly gentle even in patients who already have incurred fractures. (78) Whose fault is the poor implementation? A new survey (9) found that more than 80 percent of family physicians wanted to be better informed about bone density testing and osteoporosis treatment. However, many of these physicians felt that available guidelines were public of date or otherwise not useful. A newly come review indicated lack of guideline uniformity, grave screening rates, and low intervention rates. (10)

chiefly osteoporosis research and guideline progressive growth still are conducted by subspecialists who are unfamiliar with the unique practice demands and straits of family physicians. It is clear that family physicians ne to be involved in all phases of the process--from research to guideline formation and implementation--to make sure the construction and implementation of clinical aids that are tailored to our specialty and practice environments. Tools for screening, diagnosing, treating, and monitoring patients are available. We no longer can wait for someone besides to take charge.

REFERENCES

(1) U Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern M 2002;137:526-8

(2) Mazanec D Osteoporosis screening: time to take responsibility. Arch Intern M 2004;164:1047-8

(3) National Osteoporosis Foundation. America's bone health: the state of osteoporosis and grave bone mass in our nation. Washington, DC: The Foundation, 2002

(4) Cummings SR Melton L J 3d Epidemiology and issues of osteoporotic fractures. Lancet 2002;359:1761-7

(5) Zizic TM Pharmacologic prevention of osteoporotic fractures. Am Fam Physician 2004;70:1293-1300

(6) Cranney A, Wells G Willan A, Griffith L Zytaruk N Robinson V et al. Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women Endocr Rev 2002;23:508-16