Managing Osteoporosis: How to Create Personalized Treatment Plans

Dr. Lewiecki:
My session is about individualizing osteoporosis treatments.  And I’d like to point out, first of all, that this is the exact opposite of step therapy, which most healthcare professionals are very familiar with.  And this is the idea that we begin treatment with the cheapest drug available, and if that doesn’t work or if it’s contraindicated, we go up to the second-cheapest drug and so forth, so many health plans and healthcare organizations are fond of this approach.  And this is the exact opposite of individualizing treatment decisions where we evaluate the patient and we try to select the best drug that’s the right match for the patient in front of us, and that involves many considerations.  That includes patient preference, patient previous experience, the assessment of fracture risk, the cost of the drug, and so forth.  So these are all things that need to take place in our conversations with patients. 

Individualizing treatment decisions for patients is important because we want to match the best drug with the patient according to all available clinical information, and this is especially important in patients at very high fracture risk where we would like to have a drug that’s going to give the optimal improvement in bone density and the optimal reduction in fracture risk, especially if they’ve had a recent fracture where we want a drug that’s going to work quickly and be very potent in terms of increasing bone density.   

Every patient should be evaluated before starting treatment for factors contributing to fracture risk and determining what their risk is a little bit better than we might know previously.  So this includes measuring bone density and often assessing patients for vertebral fracture risk.  Vertebral fractures are by far the most common type of osteoporotic fractures.  About 2/3 of patients who have vertebral fractures don’t know they have them, and recognition of previously unrecognized vertebral fractures may change your diagnostic classification, it might change your assessment of fracture risk, and it might change your choice of drug for initiating therapy.  And finally, we want to do some basic lab tests for every patient, and in my mind, that includes checking the serum calcium, the alkaline phosphatase, and renal function.  I always measure a phosphorus at least once on every patient.  Once you’ve done all of that, I think you can do the best job of making a final decision on individualizing treatment decisions. 

One thing I try to keep in mind for myself and I suggest others do as well is getting to know your patient.  I think we need to develop a relationship of trust with the patient before we make treatment recommendations.  Many patients now are very concerned about the rare possibility of very rare side effects, and they often would like to consider nonpharmacological therapy as well, so we’ll go back and forth until we find something that’s acceptable for the patient and medically reasonable at the same time.