Osteoporosis Management in Respiratory Patients: An Evidence-Based Approach

Abstract

PURPOSE: Therapeutic osteoporosis trials and treatment guidelines have focused mainly on postmenopausal women. However, patient population presenting with low bone mineral density (BMD) in respiratory clinical practice is very diverse. The purpose of this evidence-based approach is to address some of the major challenges that plague physicians when treating osteoporosis for respiratory patients using derived clinical scenarios. METHODS: We identified several key practice challenges in the management of osteoporosis with respiratory diseases including patients with cystic fibrosis(CF), chronic obstructive pulmonary disease(COPD) on chronic steroid therapy, and post-lung transplant. We reviewed the literature for all publications in Pubmed and developed a flow chart for how best to manage bone health in patients with these respiratory comorbidities. RESULTS: In an evidence-based review of the literature, we have determined an approach for management of these patients. Complete assessment of risk factors for low BMD and fractures and measurement of serum calcium, phosphorus, parathyroid hormone, creatinine, alkaline phosphatase, 25-hydroxyvitamin D, and possibly thyroid and gonadal function is warranted. Stopping excessive alcohol intake and smoking, minimizing falls, calcium and vitamin D supplementation, and weight-bearing exercises has been recommended. Replacement of gonadal steroids if deficient is advisable. Current evidence supports the use of oral bisphosphonates for prevention or treatment of osteoporosis in patients with CF, chronic steroid therapy, and post-lung transplant. Efficacy of IV bisphosphonate has been demonstrated in patients with CF, chronic steroid therapy, and post-organ transplant. Teriparatide has been shown to improve BMD in patients on chronic steroid therapy. CONCLUSION: Studies in patients with CF, chronic steroid therapy and post-lung transplant have not been powered to look at fractures as an end-point, so treatment recommendations are based on the effects on the surrogate end-points(including BMD). Multicenter randomized controlled trials with long follow-up periods are needed in these patient populations to guide osteoporosis clinical care for them. CLINICAL IMPLICATIONS: This evidence based approach would be a useful tool for busy clinicians in managing these complex respiratory patients with low BMD.