Study Offers 5-Step COPD Fracture Prevention Plan

A review published online in Respiratory Research on March 7 proposed a 5-step approach aimed at preventing fractures in chronic obstructive pulmonary disease (COPD) patients.

“Although osteoporosis and its related fractures are common in patients with COPD, patients at high risk of fracture are poorly identified, and consequently, undertreated,” the authors cautioned.

By gathering an 8 person panel, Elisabeth Romme and her colleagues developed the first clinical guideline to prevent fractures in people with COPD. To create the plan, the clinical panel reviewed available literature on COPD, osteoporosis, and fracture prevention.

Using the Dutch fracture prevention guideline as a reference, the authors created a 5-pronged prevention plan, separated into the following steps: case finding using clinical risk factors, risk evaluation, differential diagnosis, therapy, and follow-up.

Case finding. To identify patients applicable for fracture risk, the writers recommended COPD patients over 50 who fulfill 2 or more criteria to undergo comprehensive risk evaluation:

● A prevalent non-traumatic vertebral fracture,

● A recent non-vertebral fracture (during the last 2 years),

● Current use of glucocorticoids (≥7.5 mg prednisone equivalents per day during at least 3 months),

● A COPD-adapted fracture risk score ≥4.

Risk Evaluation. COPD patients recommended for risk evaluation are urged to undergo hip and spine dual energy X-ray absorptiometry (DXA) and spine imaging. The panel determined patients are high-risk if any of these criteria are present:

● A prevalent non-traumatic vertebral fracture,

● Spine or hip osteoporosis

● Osteopenia with other risk factors, including a newly diagnosed vertebral fracture or other relevant risk factors (e.g. higher fall risk or elevated fracture risk assessment tool (FRAX) score).

Differential Diagnosis. The panel pressed for secondary osteoporosis or other metabolic bone disease screening, since vitamin D deficiency, secondary hyperparathyroidism, renal insufficiency, and hypogonadism have been identified as risk factors for these conditions.

The screening should cover medical history, physical examination, and biochemistry tests. To identify hyperparathyroidism, multiple myeloma, hypercortisolism, celiac disease, or other causes of secondary osteoporosis and metabolic bone diseases, the investigators advised that more comprehensive testing may be required.

Therapy. To prevent fractures, clinicians should promote lifestyle changes for COPD patients, including quitting smoking, exercise, and lowering alcohol use. Daily intake of 1000 to 1200 mg of calcium and 800 IU of vitamin D should occur via diet or supplementation.

Drug treatment should include the use of antiresorptive medications and osteo-anabolics. Based on the Dutch guideline, alendronate and risedronate are recommended as a first line of treatment due to their availability and wide-ranging effects. If the COPD patient has an intolerance to oral bisphosphonates, denosumab and zoledronate should be prescribed. For COPD patients with severe osteoarthritis, teriparatide should be administered.

The risk of glucocorticoid induced osteoporosis should be weighed by the patients’ background and dose and duration of glucocorticoid treatment.

Follow-up. Physicians should be diligent in ensuring that COPD patients adhere to and are tolerating therapy. They should also determine how long therapy should go on, and weigh how safe their current regimen is.

The experts claimed the first follow-up appointment should occur 3 months after the start of treatment, then on a yearly basis. Treatment can be changed to IV zoledronate or SC denosumab if the patient experiences oral bisphosphonate intolerance. If after one year of antiresorptive drug therapy a fracture occurs, teriparatide should be prescribed for 2 years.

After 5 years of bisphosphonate use, the authors also advised clinicians to re-evaluate risk factors such as bone mineral density (BMD) and spine imaging. If the individual is deemed to have a low fracture risk, therapy can be stopped, but reassessment should occur in 2 to 3 years. Antiresorptive treatment is to be continued in COPD patients with a high fracture risk, and should be re-evaluated after 5 years. If patients are using teriparatide, the panel suggested administering antiresorptive drugs to continue to increase BMD and structure.

Concluding their review, the researchers claimed their evidence-based systematic clinical approach is easy to use by pulmonologists and should assist in decreasing COPD patients’ fractures.