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Guideline-based osteoporosis therapy Reaching consensus on treatment

Issue 02/2020

The osteoporosis guidelines published by Dachverband Osteologie (DVO) e. V., the German osteology umbrella organization, will be updated this year. life spoke to orthopedist and trauma surgeon Prof. Dr. med. Andreas Kurth, first Chief Executive Officer of the DVO, about their significance.

Prof. Dr. med. Andreas Kurth, Head of the Department for Orthopedics and Trauma Surgery, Kemperhof, Mittelrhein Community Hospital in Koblenz, Germany, is a member of the DVO’s osteoporosis guideline committee, and, since 2015, has been the first Chairman of the association.

life: What are the challenges for a physician when treating osteoporosis?

Prof. Kurth: Osteoporosis is a slowly developing condition that becomes clinically noticeable only when symptoms arise. These symptoms are usually fractures in the typical areas, which need to be taken very seriously. The challenge for us physicians is the “case finding”. That means exploring which individual patient has what kind of risk of suffering from an osteoporotic fracture. The evaluation of various risk factors is different for every patient , and it governs the treatment.
And for surgeons in particular, the challenge is to reconstruct destroyed bones – despite poor bone quality. But the follow-up treatment of geriatric patients after treating the fracture in the hospital is also far from satisfactory: if more than 50 per cent of patients with a typical osteoporotic fracture still don’t receive guideline-based, fracture-reducing drug treatment , there’s something wrong with our healthcare system.

 

Interdisciplinary coalition

Founded in 2000, the Dachverband Osteo­logie e. V. (DVO), the German osteology umbrella organi­zation, unites all professional medical and scientific associa­tions in Germany, Austria and Switzerland focusing on bone disorders. In order to improve patient treatment – mainly those with osteoporosis – the DVO relies on three pillars: the first pillar is the evidence- based development of guidelines for all relevant questions relating to diagnosis and treatment. The second pillar is the certified further education of physicians on the subject of bone conditions according to a three-level model as an “expert in general osteoporosis manage­ment”, “expert in specialist osteo­porosis management” and “DVO osteologist”. The third pillar is the establishment and certification of “Osteology Specialist Centers”.

For more information, please visit dv-osteologie.org

 

What exactly does “guideline-based” mean and what does the S3 classification stand for in the DVO’s osteoporosis guidelines?

Prof. Kurth: Guidelines provide recommendations on how a certain condition should be diagnosed and treated. They describe a path of actions for making individual decisions for the benefit of the patient. Good guidelines are based on the latest scientific findings, and their recommendations can be implemented in everyday medical practice. All over the world, there are now uniform standards for the creation of guidelines. In Germany, the Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) coordinates their deve­lopment. They divide guidelines into four categories: S1, S2k, S2e and S3. S3 guidelines are the most reliable, but also the most complicated to create, and they generally need to be renewed every three to five years. The committee is staffed with representatives from different specialist areas, and knowledge is systematically collected and assessed. And there is a structured procedure for deciding on a standardized recommendation if there are different opinions within the committee.

“If more than 50 per cent of patients with osteoporotic fractures don’t receive guideline-based treatment,
there’s something wrong with the healthcare system.”
Prof. Andreas Kurth

What do you advocate as a member of the guideline committee?

Prof. Kurth: As an orthopedist and trauma surgeon, I find the development of integrated treatment models for the prevention of osteoporosis-related subsequent fractures very important. These Fracture Liaison Services (FLS) have a clear structure for the surgical treatment of an osteoporotic fracture and follow-up care that are gathering increasing evidence.

 

Using bone densitometry (bone mineral density assessment), osteoporosis can be detected early.

What changes will the update of the guidelines in 2020 include?

Prof. Kurth: The risk factors for osteoporotic fractures have significantly increased over the last few years. To ensure that patients aren’t disadvantaged during the assessment of their individual fracture risk, we must correctly evaluate all these scientifically proven factors and make them available in a risk algorithm. This has become very complex, stretching the algorithm that has been tried and tested for years reaches to its limits, and we’re doing all we can to create a digital risk calculator. It will be available as an app and a web-based solution. The guideline committee developed the scientific basis using international literature. At the moment , a validation of the current risk factors is being carried out with the help of a large study group. That’s another important evolutionary step in guideline work. Otherwise, not much will change at the moment , which we feel is a positive thing. That shows that even recommendations from 20 years ago are still valid today, based on evidence.

“In cases of vertebral fractures, the primary goal is pain reduction.
That can be achieved with an orthosis or minimally invasive surgical intervention.”
Prof. Andreas Kurth

 

What role does non-surgical treatment play in cases of osteoporosis?

Prof. Kurth: It’s one of the main pillars of therapy. In addition to basic treatment by substituting calcium and Vitamin D, physical activity, in particular, plays a vital role in the prevention of subsequent fractures. There is close interaction between bones and muscles. Strengthening of muscles also leads to an improvement in bone quality. If the fracture risk is significantly increased, active anti-osteoporotic treatment must be initiated.

What does treatment focus on?

Prof. Kurth: It depends on the individual’s baseline condition, which can vary widely. Take, for example, a patient with COPD on cortisone treatment; a 77-year-old with prostate cancer, hormone deprivation therapy and multiple vertebral fractures; or a 91-year-old woman with a painful pelvis fracture who doesn’t remember any traumatic event… If there are osteoporotic fractures, they usually have to be treated surgically, with the goal of restoring functionality and mobility. In cases of vertebral fractures, the primary goal is: pain reduction. That can be achieved with an orthosis or minimally invasive surgical intervention. Treatment with the right medication is a must for almost all the patients described.

Are there differences in treatment between early stages and advanced stages?

Prof. Kurth: The guidelines don’t differentiate there. The “case finding” – that is: which patient has a high or higher risk of suffering from a fracture – provides a threshold level. If a fracture probability of 30 per cent is exceeded, effective treatment with anti-osteoporotic medication must be initiated. Studies from the last two years show that for high-risk patients, osteoanabolic treatment should be favored over anti-resorptive treatment. If the risk is below 30 per cent , basic treatment with calcium, Vitamin D, and physical activity should be recommended.

DVO’s 2017 Osteoporosis Guidelines

The guidelines provide clear recommendations on prevention, diagnosis and treatment in medical practice for post-menopausal women and for men. They were published in the professional magazine “Osteologie” (Georg Thieme Verlag), and, in 2018, received the Thieme Osteology Award for an article that “significantly improves the quality of treatment and quality of life for a growing patient group”. In 2020, an update is due. Please find the long version of the evidence and consensus-based osteoporosis guidelines at

dv-osteologie.org/osteoporose-leitlinien

When are orthoses recommended that straighten the spine?

Prof. Kurth: The general rule for all osteoporotic vertebral fractures is that both non-surgical treatments with orthoses as well as surgical procedures are available. Treating osteoporosis with orthoses is just one of many elements used and an efficient measure to improve the situation in cases of existing kyphosis in the thoracic and lumbar spine. The purpose of these orthoses is usually a restriction of mobility in the affected sections of the spine while, at the same time, training the supporting and stabilizing muscles. This can reduce acute problems and pain caused by collapsed vertebral bodies and fractures. To appropriately account for the characteristics of multilocular pain symptoms as well as for the general changes in cases of osteoporosis, targeted selection of the orthosis type is required: rigid orthoses should only be used for as long as absolutely needed. For non-operable osteoporosis patients who suffer from severe pain and for whom medication isn’t effective straight away, dynamic orthoses are an important option. The same applies to patients with multiple previous osteoporotic fractures, a high risk of subsequent fractures and significant misalignments.

What are the differences between the orthosis types?

Prof. Kurth: We differentiate between passive and active spinal orthoses. A passive orthosis can be compared to a support corset that primarily provides relief. Active orthoses, on the other hand, are designed to contribute to active correction and encourage better posture, in addition to providing support. They provide stability and support when vertebral fractures or pain make everyday movements difficult – and they straighten the spine and strengthen the muscles.
In cases of collapsed vertebral bodies in the lower thoracic spin associated with the common wedge-shaped deformation, a reclining orthosis with a 3-point effect (e.g. according to Bähler-Vogt) is usually indicated. There are recommendations indicating that the affected vertebral body shouldn’t be higher than T8. The use of a hyperextension orthosis is limited even if there are asymmetric osteoporotic fractures or if an instability must be assumed in several affected vertebrae.
Activating and dynamic torso orthoses have been developed in order to support physical activity and to encourage the correct posture in patients when standing, which also contributes to prevention. They consistently counteract increased kyphosing of the thoracic spine and should already be used in cases of painful early-stage osteoporosis with initial kyphosis. These orthoses are put on like a backpack. The torso’s range of motion is only slightly restricted, the freedom and mobility of the arms support important muscle functions. They promote active posture correction during the remineralization phase, which usually takes a long time.

What should patients know about treatment with orthoses?

Prof. Kurth: The general rule is: when being provided with the correct product , patients should be pain-free or at least feel less pain after the orthosis has been put on. This goal must be checked by the carer and the physician. If patients mention pain when moving with the orthosis, the correct fit must be checked.
I know from my experience that it’s really important to discuss the use of an orthosis with patients. They must be educated about its purpose and the duration of its use, which is usually eight to twelve weeks. For older patients in particular, it may be difficult to put on an orthosis and uncomfortable in the long term. That’s why the patient’s preference must always be considered when indicated treatment is decided. An orthosis that disappears in the cupboard after a few days can’t help.

 

Strengthening bones together

The DVO and its expert associations have joined forces with pharmaceutical companies and medical technology manufacturers, forming OSTEOLIGA. The goal of this initiative is to raise public awareness of osteoporosis, to improve treatment and to strengthen expert networking and exchange. Bauerfeind has been a member and supporter since 2016 and is active within this network as a manufacturer of spine-straightening orthoses. For more information and material , such as the eight-page “white-coat pocket version” of the DVO’s guidelines, please see

osteoliga.de

 

Images: GK-Mittelrhein, iStockphoto.com/CreVis2/izusek


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