Multidisciplinary Consensus on the Prevention and Treatment of Osteoporosis and Fragility Fractures in Patients with Prostate Cancer Receiving Androgen-Deprivation Therapy.

Patients with prostate cancer (PCa) on androgen-deprivation therapy (ADT) are at high risk of osteoporosis and fragility fractures. We aimed to provide some practical insights into the delivery of optimal bone health care for PCa patients, particularly those on ADT. An interdisciplinary group of experts, including urologists and rheumatologists developed recommendations based on their expertise, current evidence and guidelines. The multidisciplinary group's main recommendations are: fragility fracture risk should be assessed in all PCa patient, especially, in those under ADT. FRAX® tool may be incorporated into clinical practice to identify patients at high risk of fracture. Bone mineral density (BMD) should be measured routinely by dual energy X-ray absorptiometry in all patients scheduled for or on ADT. Thoracic and lumbar spine X-ray may be performed at the initial evaluation of patients with the diagnosis of osteoporosis and in case of suspected clinical vertebral fracture. Basic laboratory tests are recommended to exclude secondary osteoporosis. Treatment with bisphosphonates or denosumab should be considered in patients on ADT with fragility fracture, osteoporosis (BMD T-score ≤-2.5), or high risk of fracture according to FRAX®. Referral to a bone metabolism specialist should be contemplated in some cases. The recommendations provided in this document, tailored for clinicians treating PCa patients, may be of help to identify and treat patients at high risk of fracture.

Defining high risk of osteoporotic fracture: a cross talk between clinical experience and guidelines recommendations.

BACKGROUND: : There is no universally accepted definition for patients at high risk of osteoporotic fracture. OBJECTIVES: : This study aimed to survey Spanish rheumatologists; to obtain opinions about risk factors, and an acceptable definition for patients at high risk of osteoporotic fracture; and to compare daily practice patterns with current osteoporosis guidelines. METHODS: : A total of 174 rheumatologists from throughout Spain completed an online survey about various risk factors for fragility fracture and about the management of patients with osteoporosis in clinical practice. Results were reviewed by a coordinating committee of osteoporosis experts and were compared with published national and international guideline recommendations. RESULTS: : Almost all rheumatologists who completed the survey (99%) consider that a group of patients exists with a high risk of osteoporotic fracture and that this group should be managed appropriately. Previous fracture is considered the most important risk factor, particularly in cases of multiple fracture, severe vertebral fracture, hip fracture, or fracture despite osteoporosis treatment. However, in osteoporosis guidelines, age, bone mineral density, and previous fragility fracture are the most important risk factors for new fracture. Furthermore, Spanish rheumatologists tend to treat patients at high risk of fracture with anabolic therapy (e.g., teriparatide), whereas guidelines make no such recommendation. CONCLUSIONS: : In osteoporosis, a large gap exists between implementation of guideline recommendations and actual clinical practice; this may be due, in part, to heterogeneity among existing guidelines. Thus, inclusion in guidelines of a practical definition of high risk of osteoporotic fracture may provide significant opportunities to improve patient care and prevent future fragility fractures. KEY POINTS: :

[Management of the patient with a high risk of fracture in clinical practice. Results from a survey of 174 Spanish Rheumatologists (OSTEOPAR project)]. / Manejo del paciente con alto riesgo de fractura en la práctica clínica. Resultados de una encuesta a 174 reumatólogos españoles (proyecto OSTEOPAR).

OBJECTIVE: To collect information about diagnosis, classification and treatment of patients at high risk of fracture in the rheumatologist's practice. MATERIAL AND METHODS: A survey was conducted among Spanish rheumatologists. The survey was aimed at gathering data on the physician's healthcare activity, the osteoporosis (OP) and fracture risk factors considered as most relevant, the diagnostic used tests and the treatment indication according to the presence of different risk factors. RESULTS: 99.5% of rheumatologists felt that there is a group of patients with OP at high risk of fracture. Previous fracture was considered the most important risk factor, particularly in case of multiple fractures, severe fractures, hip fracture, or that occurred during treatment. Glucocorticoid treatment, older age and low bone mineral density were considered, in this order, other important risk factors. The number of vertebral fractures was considered the most relevant radiological data, followed by the fracture's chronology and severity. Most of the respondents selected teriparatide as the first treatment option in high-risk patients. CONCLUSIONS: The definition of OP patient with high risk of fracture is not uniform in daily practice, although the majority of rheumatologists considered that having a previous fracture is the most important risk factor, followed by glucocorticoid treatment, older age and low BMD. Anabolic treatment was the approach most commonly used in OP patients with high risk of fracture.