Alternative Treatments and HRT for Effective Management of Osteoporosis

1. Which Method Either Alternative Treatments Or Hrt Will Be Effective Against The Osteoporosis To Receive Spasticity Control And Better Management Of Osteoporosis?

Osteoporosis is a global wide disorder which is described by decrease in the bone mass and change in the bone framework and as a result it increases bone fragility and increases the chances of risk of fracture (Sözen, Özışık & BaÅŸaran, 2017). According to the National Institutes of Health Consensus Development Panel on Osteoporosis, it has been described as a skeletal condition described by decrease in the bone strength which causes an elevated risk of fracture.” The frequency of osteoporosis is considered to rise ominously in the near future as a result of growing age of the population. Osteoporosis has been seen to occur majorly in the postmenopausal females and elderly men (Akkawi & Zmerly, 2018). In the study of Akkawi and Zmerly (2018), it has been stated that around 200 million individuals agonize because of osteoporosis and roughly 8.9 million fractures occur as a result of osteoporotic fracture. These fractures has been seen to occur in the hip, vertebrae, and distal forearm and are linked to substantial injury, death, and decrease in the quality of life, endorsed not only to the fracture itself but also to the high occurrence of comorbidities in the population of patients. Furthermore, osteoporosis shows a distressing alarm to the health care industry as a result of its elevated economic burden. In the United States, costs related to osteoporosis fractures were estimated at $13.8 billion (Akkawi & Zmerly, 2018).

As concerns regarding the osteoporosis is increasing across different healthcare sectors with its impact on the quality and quantity of life, guideline that is American Association of Clinical Endocrinologists (AACE) have been developed in the hope of decreasing the threat of osteoporosis-related fractures and thus preserving the quality of life for individuals suffering from osteoporosis (Handelsman et al., 2015). This guideline utilizes the best available evidence, taking into thought the economic crisis of the condition and the requirement for an effective and efficient assessment and management of people with osteoporosis. The intention is to deliver evidence-based details regarding the diagnosis, assessment, and management of osteoporosis for endocrinologists, healthcare professionals in general, regulatory bodies, health-related institutions, and concerned laypersons (Camacho et al., 2016).

The following report will summarize the current AHRQ-NGC guidelines and conduct a literature review on the osteoporosis. The research question on the basis of which the literature review will be conducted will be developed using the PICO model.

• Data sources:For conducting a literature review several electronic databases were used to collect the articles like PubMed, CINAHL, Scopus, NCBI, Cochrane, Google Scholar and Web of Science. Through these electronic databases only articles which were published in English language on osteoporosis guidelines specifically the AHRQ guidelines within the period of 2018 – to latest date were selected.
• Search terms/keywords:The major keywords which helped in better selection of the articles were “osteoporosis” or “AHRQ guidelines” and Boolean operators were used to do subsequent searches such as guidelines and elderly people; osteoporosis or AHRQ guidelines.

• Those papers which were published within the time frame of 2018-2020 were only selected for the literature review.
• Papers which have been published in English language have only been selected for the literature review.
• Different quantitative, qualitative, journals and articles were used to gather information on the AHRQ guidelines of osteoporosis.

• Those papers which were published before the time frame of 2018-2020 were not selected for the literature review.
• Papers which have been published in any other language except English have not been selected for the literature review.
• Papers which did not contain the relevant keywords were not selected for the literature review.

Cochrane Library

In the paper of Wojdasiewicz, Turczyn, Dobies-Krzesniak, Frasunska and Tarnacka (2019) the researchers searched for several studies and collected sufficient evidence regarding the role of the CX3CL1/CX3CR1 axis in procedures which results in the reduction of bone mineral density (BMD). The CX3CL1/CX3CR1 axis has a significant function in the maturation of osteoclast and attaching them with the immune cells to the wall of the bone tissue. It enhances the growth of inflammation and manufacture of several inflammatory cytokines surrounding the bone surface (i.e., TNF-α, IL-1β, and IL-6). The paper has also stated that high amount of bone turnover and inflammatory elements in human blood serum (TRACP-5b, NTx, IL-1β, and IL-6) are directly proportional to the high amount of CX3CL1 in serum. Accordance to the feature that working contrary to the CX3CL1/CX3CR1 axis is a prospective goal of immune treatment in osteoporosis, though the available amount of research papers regarding the topic is inadequate. Thus, the researchers suggest further research is necessary which would accurately recognize its function in the metabolism of the bone tissue which is one of the most significant targets in osteoporosis therapy (Wojdasiewicz, Turczyn, Dobies-Krzesniak, Frasunska & Tarnacka, 2019).

In the paper published by Osteoporosis Surveillance Expert Working Group, (2018), it has been observed that 1.5 million Canadians above the age of 40 were diagnosed with osteoporosis. Majority of the people reported that they were prescribed to take vitamin D and calcium supplements along with other medicines. Though, it was also seen that several Canadians who had a risk of fracture or had a fracture history, did   not receive bone density testing and were not participating in lifestyle approaches which would have helped them to maintain their bone condition. Thus, the researchers tried to deliver a nationwide standard which would be followed during the osteoporosis examination, inhibition and maintenance in the Canadian population aged 40 years and older (40+) using the information gathered from the publication which has been collected one year prior to the publication of Osteoporosis Canada’s (2010) clinical practice guidelines (Osteoporosis Surveillance Expert Working Group, 2018). 

In the paper of Bisson, Finlayson, Ekuma, Leslie and Marrie (2019), the researchers tried to relate the measurements of bone mineral density (BMD) among the individuals who are not and are diagnosed with multiple sclerosis (MS). For the study, the researchers collected information from the population of Manitoba, Canada who have undergone BMD screening and controls. The researchers collected BMD T-scores for the femoral neck, hip, and lumbar spine and also tried to check the occurrence of osteoporosis. It was seen that the BMD T-score was lower in the MS cases compared to the matched controls. Also, the frequency of osteoporosis was higher in the MS cases than those of the controls. It was concluded that people who were living with MS, had low BMD, but high frequency of osteoporosis compared to the people with similar age and sex but without MS. Thus, it has been suggested that bone analysis is highly important in the cases of MS (Bisson, Finlayson, Ekuma, Leslie & Marrie, 2019).  

In the research paper by Curry et al., (2018), the researchers tried to update the US Preventive Services Task Force (USPSTF) which was published in the year 2011 and provide recommendation for the screening of osteoporosis and to be updated in the USPSTF. The researchers found that bone measurement tests, clinical risk assessment tools are highly precise in the detection of osteoporosis and detection osteoporotic fractures in women and men. It was also found that drug therapies are highly significant in the reduction of incidence of fracture in postmenopausal women. Though there were limited amount of evidence which would show the effectiveness of the drug therapies. Thus, USPSTF recommended that bone measurement testing should be used for the screening for osteoporosis in order to prevent osteoporotic fractures in women 65 years and older. It also concluded that there is little evidence which suggests balance of advantages and disadvantages of screening for osteoporosis (Curry et al., 2018).

In the paper by Gibbs, MacIntyre, Ponzano, Templeton, Papaioannou and Giangregorio (2019), the researchers tried to assess the advantages and disadvantages of the exercise approach (like the physical therapy intervention) for over 28 days and more which was compared with the non‐active physical therapy approach, no approach or placebo between the people who have a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. The paper had another goal, which was to assess the effects of physical activity on the following consequences: accidental falls, feeling pain, physical activity presentation, health‐related quality of life (disease‐specific and generic), and adverse events. After the selection of the research papers and filtering the papers according to the selection criteria, nine trials including 749, 68 male participants were involved in the study. Due to the considerable inconsistencies across the trials it prohibited any meaningful pooling of information for most probable results. The danger of bias throughout all the studies were different; little danger throughout most domains in four studies, and uncertain/high danger in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias. The researchers suggested that there were limited amount of evidence which would show the effects of exercise on incident fractures, falls or adverse events (Gibbs, MacIntyre, Ponzano, Templeton, Papaioannou and Giangregorio, 2019).

In another paper by Fink et al., (2019), the researchers summarized the impact of long-term osteoporosis drug treatment (ODT) and ODT cessation and breaks on fractures and harms. To collect the articles for the study, the researchers used Medline, Cochrane, and Embase and the timeframe was 1995 to October 2018. They described the long-term ODT as >3 years and ODT holidays as cessation for ≥1 year after ≥1 year of use. Trials were utilized for accidental fractures and injuries, and controlled observational studies were involved for further injuries. 61 English published papers were involved in the study. It was concluded that long-term alendronate, zoledronate, and oral hormone treatment decreased non-vertebral fractures in elderly females, with oral hormone treatment also decreasing hip fractures. While complete decrease in characteristic fractures with long-term bisphosphonates are large compared to increase in atypical femoral fractures (AFF), decreased hip fracture threat with oral hormone treatment appears offset by elevated danger of severe injury. Evidence is inadequate concerning ODT holidays for fractures and injuries. Further research is required, involving randomized trials comparing ODT holiday durations and sequential treatments powered for clinical fractures, and controlled cohort studies of ODT holidays to estimate rare harms (Fink et al., 2019).

The following recommendations are based upon the guideline which is created by the American Association of Clinical Endocrinologists (AACE), with the aim of decreasing the danger of osteoporosis-related fractures and thus managing the quality of life for individuals suffering from osteoporosis (AACE, 2016). The AACE suggests that 

• If the T-score for any of either lumbar spine, femoral neck or total hip is ≤ -2.5, and if the individual has a history of fragility fracture or if the person has a 10 year history of osteoporotic fracture risk ≥ 20% or hip fracture risk ≥ 3%, then it is needed to evaluate the cause of secondary osteoporosis.
• If the cause is calcium/vitamin D deficiency, then it should be managed and the cause of secondary osteoporosis should be addressed. Pharmacologic therapy is to be recommended. Also, the patient is to be given education regarding the lifestyle changes, how to prevent themselves from falling down, and guiding them about the advantages and disadvantages of medicines (AACE, 2016).
• If the person has no history of fragility fractures or has a moderate risk of fracture, then Alendronate and denosumab are suggested. The alternate therapy for such people are ibandronate and raloxifene (AACE, 2016).
• For people who have a history of fragility fractures, denosumab, teriparatide and zoledronic acid has been suggested. Alternate therapies for such people are alendronate and risedronate (Knezevich & Spangler, 2019).

References

AACE. (2016). AACE/ACE 2016 Postmenopausal Osteoporosis Treatment Algorithm. Retrieved 5 March 2020, from https://www.aace.com/pdfs/bone/AACE_Postmenopausal_Osteoporosis_Treatment_Algorithm.pdf

Akkawi, I., & Zmerly, H. (2018). Osteoporosis: current concepts. Joints, 6(02), 122-127.

Bisson, E. J., Finlayson, M. L., Ekuma, O., Leslie, W. D., & Marrie, R. A. (2019). Multiple sclerosis is associated with low bone mineral density and osteoporosis. Neurology: Clinical Practice, 9(5), 391-399.

Black, D. M., & Rosen, C. J. (2016). Postmenopausal osteoporosis. New England Journal of Medicine, 374(3), 254-262.

Camacho, P. M., Petak, S. M., Binkley, N., Clarke, B. L., Harris, S. T., Hurley, D. L., ... & Pessah-Pollack, R. (2016). American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2016. Endocrine Practice, 22(s4), 1-42.

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., ... & Landefeld, C. S. (2018). Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. Jama, 319(24), 2521-2531.

Eastell, R., & Szulc, P. (2017). Use of bone turnover markers in postmenopausal osteoporosis. The Lancet Diabetes & Endocrinology, 5(11), 908-923.

Fink, H. A., MacDonald, R., Forte, M. L., Rosebush, C. E., Ensrud, K. E., Schousboe, J. T., ... & Taylor, B. C. (2019). Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review.

Gambacciani, M., & Levancini, M. (2014). Hormone replacement therapy and the prevention of postmenopausal osteoporosis. Przeglad menopauzalny= Menopause review, 13(4), 213.

Gibbs, J. C., MacIntyre, N. J., Ponzano, M., Templeton, J. A., Thabane, L., Papaioannou, A., & Giangregorio, L. M. (2019). Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database of Systematic Reviews, (7).

Handelsman, y., Bloomgarden, z. t., Grunberger, g., Umpierrez, g., Zimmerman, r. s., Bailey, t. s., ... & Davidson, j. a. (2015). American Association Of Clinical Endocrinologists And American College Of Endocrinology–Clinical Practice Guidelines For Developing a Diabetes Mellitus Comprehensive Care Plan–2015—Executive Summary: Complete Guidelines Are Available At Https://Www. Aace. Com/Publications/Guidelines. Endocrine Practice, 21(4), 413-437.

Knezevich, E., & Spangler, M. (2019). Updates in the Treatment of Postmenopausal Osteoporosis. US Pharm, 44(9), 32-35.

Osteoporosis Surveillance Expert Working Group. (2018). Original quantitative research Screening, prevention and management of osteoporosis among Canadian adults. Health promotion and chronic disease prevention in Canada: research, policy and practice, 38(12), 445.

Sözen, T., Özışık, L., & BaÅŸaran, N. Ç. (2017). An overview and management of osteoporosis. European journal of rheumatology, 4(1), 46.

Wojdasiewicz, P., Turczyn, P., Dobies-Krzesniak, B., Frasunska, J., & Tarnacka, B. (2019). Role of CX3CL1/CX3CR1 Signaling Axis Activity in Osteoporosis. Mediators of inflammation, 2019.