Whoa Doctor, Not So Fast With That Osteoporosis Prescription!
Thursday, August 25, 2011
Last week I worked with a patient who was 55 years old. Her internist told her that she lost 8% bone mass in just one year and that she needed to start Fosamax immediately. She came to me to review her case for a second opinion. In the beginning, all she had was the DXA report written by the reporting doctor. My first request was to obtain the computer printout for both studies. In order for me to assess a case I need to view the computer printout for bone exams so that I can compare them. The pages contain the diagnostic information, including small x-rays that appear for the lumbar spine and hip. These small x-rays are essential diagnostic information needed for comparison. Here are some of the things I check when I look at the DXA diagnostic pages:
- Patient positioning is critical and it takes a trained eye to make sure the areas of interest are exactly the same.
- Hip Positioning – is the rotation of the femur exactly the same? Too much or too little rotation can skew the findings by as much as 5-15%! Was the region of interest selected correctly?
- Lumbar spine - were the lines in the lumbar spine placed correctly on the lateral margins of the vertebra and were the correct vertebra selected?
- If it is a comparison study was the second comparison DXA taken at the same location on exactly the same machine – the serial number should be on the report
- Was the same software used for the analysis?
- Has the facility posted their least significant change (LCC)? That is the amount of change that is REAL. If a facility does post this they are at least making an attempt to utilized correct procedures. The LCC for the same machine is 2.77% and as for different machines – NO reliable comparison can be made.
Similar to reading x-rays there are many additional things I look for before rendering my opinion of the bone density exam, especially comparison views.
As it turned out my new patient was able to breath a sigh of relief. Not only had she not lost bone mass but her low bone mass was not clinically significant, and therefore she was not actively losing bone. I had the bone density clinic reanalyze the bone density tests. The technician who performed the follow-up study did not select the proper area for evaluation. In this case, the technician can simply reanalyze the study. For this patient, exercise and nutrition were reasonable choices at this time. Clearly, not everyone is so lucky.
I have spent years studying osteoporosis. Here are some of the lessons I have gleaned over the years:
- A single bone density test cannot determine that bone loss is occurring – you may have stable low bone density – to know if you are actively losing bone requires lab tests or two consecutive bone density studies for comparison (from the exact machine).
- A very high percentage of people on medications do not need to be on them.
- The vast majority of patients who are diagnosed with low bone mass or osteoporosis have not been worked up properly. This means that either no lab work was ordered or incomplete lab work was ordered.
- There is a rush to put patients on medications.
- When patients are prescribed medications they are frequently prescribed ones that are not the best for their individual situation.
- Most doctors do not take the time to look for underlying causes and resolve them in patients who are actively loosing bone. For instance, if a patient has a digestive disorder that is causing a malabsorption of nutrients it is critical to resolve such digestive problems. Excessive symptoms of bloating, gas, burping or heartburn are not normal.
- Most digestive problems can be resolved naturally. Medications such as proton pump inhibitors result in bone loss.
- Some people do need to be on medications who have serious osteoporosis or who have sustained a fragility fracture, that is, a fracture that should not have occurred and with minimal trauma.
- Most doctors do not evaluate the nutritional status of a patient, which should be the core of any bone-building program with or without medications. Your doctor should have you fill out a diet diary before your initial visit – it is that important!
A lot goes into assessing each patients bone health. Bone density is one aspect and it is a great tool if it is used correctly. If you have been diagnosed with low bone density or osteoporosis learn all you can so that you can be an informed patient.