Monitoring and Treating Osteoporosis

Peter L. Salgo, MD: If you make the diagnosis of osteoporosis, let’s beat up the payers a bit more, how often will a payer pay to screen again? Is it every year they’ll pay, or every 2 years, or 5 years?

Thomas P. Olenginski, MD, FACP, CCD: Typically, in my neck of the Pennsylvania woods, if it’s Medicare, it’s typically every 2 years. For a patient on steroids, typically every year; steroid-related bone loss is more rapid, is sustained. You have to be a little more careful.

Peter L. Salgo, MD: That’s not so bad, actually.

Thomas P. Olenginski, MD, FACP, CCD: I think sometimes if there’s something that’s happened, namely a fracture and you’re thinking of changing, if you need that, they’ll often do it. I think the payers, in this regard, are much more reasonable than the general current legislation, which really makes it hard to screen men.

Peter L. Salgo, MD: We talked about these generic things. There are medications, and we’re going to talk about more medications. There are the generic things, and exercise, and eating properly, and vitamin D. Does that differ for men versus women? Is it the same disease across gender?

Thomas P. Olenginski, MD, FACP, CCD: It is the same disease. Now, I wouldn’t tell this to men, but estrogen deficiency in men is “the real McCoy.” Basically, men get the same fractures. Men have a harder time doing better post-fracture than women, and I don’t think we know that. Most of the therapies have been better studied in women. But take away estrogen, the bisphosphonates and other medicines we’re going to talk about are effective.

Peter L. Salgo, MD: And if you take a look at all-comers in terms of age, do you change your therapy based on how old the person is?

Andrea J. Singer, MD, FACP, CCD: You might. There are a number of factors that I think go into deciding with which therapy you should start, and what the sequence over time might look like. For younger patients, we might have a slightly different approach. But a lot of it is really based on risk. What is their risk for fracture? And for the highest-risk patients, that approach may be different than for somebody who’s high risk. We are only treating high-risk patients, but we know about lower high-risk as opposed to the highest high-risk.

Peter L. Salgo, MD: Do comorbidities factor into this as well?

Andrea J. Singer, MD, FACP, CCD: Absolutely.

Peter L. Salgo, MD: How so?

Andrea J. Singer, MD, FACP, CCD: There are some things, from a comorbid standpoint, that might preclude the use of a certain medication, or for which a certain medication may help other situations as well. So I think we need to look at the total patient.

I want to go back to one thing Tom said about men. One of the problems is, as poor a job as we do recognizing fractures in women as indicating an underlying disease, there’s a lot more denial when it comes to men. He’s a guy. He’s got bigger, stronger bones, right? He shouldn’t have osteoporosis. And so that recognition, that evaluation, and ultimately treatment—those numbers are far worse in men than they are in women.

Peter L. Salgo, MD: You know what it sounds like to me? A generation ago, maybe a little less, it was, “Women don’t get heart attacks. That chest pain of yours, that’s something else.” Until somebody woke up. It’s just flipped over, isn’t it?