Pulmonologists Unaware of High Osteoporosis Risk in Patients With COPD

Key Point

Pulmonologists are generally uninformed about the significant risk of osteoporotic fractures in patients with COPD and the benefits of screening and preventive therapy for their patients.

CHICAGO—A significant number of patients with COPD face the burden of bone fractures in addition to impaired lung function. Osteoporosis and COPD share several risk factors and patient characteristics, including advanced age, low levels of physical activity, low BMI, smoking history, and history of corticosteroid treatment. Yet many physicians who treat COPD are unaware of the high osteoporosis risk among their patients and are unfamiliar with recommended screening and treatment approaches for these patients, a new survey found.

Speaking at the American College of Chest Physicians (ACCP) Annual International Scientific Assembly, Nicola Hanania, MD, presented the results of a survey conducted among ACCP members to determine clinician awareness of osteoporosis risk factors in patients with COPD. Among the 481 respondents (93% pulmonologists), the majority (67%) answered that inhaled corticosteroid therapy represented a low risk factor for osteoporosis, while almost 20% said that COPD itself was associated with low risk for osteoporosis. Almost all respondents (91%) said they had access to bone densitometry testing for their patients, yet only 25% said they had referred any patient for this test within the past three months.

PREVALENCE AND MORBIDITY OF OSTEOPOROSIS IN COPD

Post hoc analysis from the large population enrolled in the Towards a Revolution in COPD Health (TORCH) trial revealed an osteoporosis/osteopenia prevalence of approximately 70% in patients with COPD, with the rates in men with COPD (50% to 60%) almost as high as those seen in women (60% to 70%). As the severity of COPD increases, so does the risk of osteoporosis and related complications. Use of oral glucocorticoids in advanced stages of COPD is one obvious reason. A classic study by McEvoy and colleagues showed that male COPD patients using oral glucocorticoids have a 1.8-fold higher incidence of vertebral fractures compared with those who do not.

However, oral steroids are not the sole explanation, as COPD patients have more osteoporosis than the general population regardless of medication history, noted Dr. Hanania, who is Associate Professor and Principal Investigator of the Asthma Clinical Research Center at Baylor College of Medicine in Houston.

The connection between inhaled corticosteroids and osteoporosis has been more controversial. Post hoc analysis of US data from the TORCH trial showed no increased incidence of low bone mineral density (BMD) in patients treated with a combination of fluticasone and salmeterol and those receiving placebo over a three-year period. Other authors have shown that patients using moderate or high doses of inhaled glucocorticoids over long periods are at increased risk for fractures and should be monitored for bone loss.

Low BMD remains asymptomatic until a fracture occurs. Vertebral fractures are common in COPD and often go unrecognized. Patients who sustain vertebral fractures may not notice the symptoms, or they may attribute back pain to other sources. Over time these fractures lead to deformity, pain, and reduced mobility. Hip fractures significantly increase morbidity and mortality in any patient and particularly those with serious diseases. According to the NIH, one-year mortality among patients sustaining an osteoporotic hip fracture is 20%. “Osteopenia and osteoporosis should be detected as early as possible in the course of lung disease so that preventive measures can be taken before fractures develop,” Dr. Hanania advised.

WHO SHOULD BE SCREENED FOR OSTEOPOROSIS?

The US Preventive Services Task Force currently recommends routine bone density screening for all women 65 or older, and starting at age 60 for those who have an increased risk for osteoporosis. Although the risks are not clearly defined in this report, the prevalence of osteoporosis in both men and women with COPD is similar to that of postmenopausal women without COPD, suggesting that any COPD patient would benefit from screening.

The task force also states that BMD measured at the femoral neck by dual-energy x-ray absorptiometry is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. The World Health Organization defines osteopenia as BMD between 1 and 2.5 standard deviations below the reference range (the mean BMD expected for young adults of the same sex) and defines osteoporosis as BMD more than 2.5 standard deviations below the mean. This calculation represents the T score and is accurate for diagnosis of bone loss in postmenopausal women and in men 50 and older, according to the International Society for Clinical Densitometry. The Z score represents BMD relative to matched controls of the same age, sex, and ethnic status and may be useful for diagnosing secondary osteoporosis in younger patients.

In the recent ACCP survey on which Dr. Hanania reported, only 37% of those surveyed were able to correctly identify the T score associated with a diagnosis of osteoporosis in a sample case scenario. The researchers concluded that pulmonologists have “significant deficiencies” in knowledge about osteoporosis risk and require further education on this subject. In fact, 89% of those surveyed agreed that they needed to improve their knowledge of osteoporosis risk, screening, and management.            

—Katherine Wandersee

Suggested Reading
Calverley PM, Anderson JA, Celli B, et al. Salmet-erol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356(8):775-789.
Kaza V, O Brien JD, Hanania NA. Osteoporosis in chronic lung disease: physicians’ perceptions and management practices. Chest. 2007;132(4):427S.
McEvoy CE, Ensrud KE, Bender E, et al. Association between corticosteroid use and vertebral fractures in older men with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;157(3 Pt 1):704-709.
National Institutes of Health. Osteoporosis prevention, diagnosis, and therapy: Consensus Development Conference statement. March 27-29, 2000. Available at: consensus.nih.gov/2000/2000Osteoporosis111html.htm. Accessed November 27, 2007.
Tattersfield AE, Harrison TW, Hubbard RB, Mortimer K. Safety of inhaled corticosteroids. Proc Am Thorac Soc. 2004;1(3):171-175.
US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. September 2002. Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm. Accessed November 27, 2007.

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