Decades of experience with osteoporosis

Bone density is a powerful predictor of fractures, but it’s not the only thing that puts people at risk. Doctors at the Yale Bone Center take a comprehensive look at the whole picture.

Karl Insogna MD, discusses a treatment plan with Mary McCarthy, his patient.

(February 2012) Three years ago, when Mary McCarthy asked her primary care physician if she should have her bone density tested, her doctor was skeptical. At 54, McCarthy was still a bit young. However, she knew that her thin wrists and slight build put her at higher risk for the condition.

The results of her bone densitometry test at the Yale Bone Center were surprising. Karl Insogna, MD, director of the center, diagnosed osteoporosis in McCarthy’s spine and osteopenia (bone density that is lower than normal) in her forearm and left femoral neck.

“Many of my patients have hip and spine fractures, so I was extremely concerned that this would be my fate,” says McCarthy, an occupational therapist who works with elderly patients.

Powerful predictor of fractures

Osteoporosis makes bones weak and more likely to break; as many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis.

“Bone density is a very powerful predictor of your risk for fracture, but it’s not the only risk,” says Dr. Insogna. Other factors can play a role and are used to calculate a person’s 10-year risk for fracture. They include:

• Family history of fractures, especially if a parent had a fracture after the age of 50
• Ethnicity: African-Americans, for example, have a higher bone density than Caucasians and a lower risk for fracture at any given age.
• Having a small, thin frame
• Certain medications, such as steroids
• Conditions such as rheumatoid arthritis.

At Yale, patients complete a questionnaire about their lifestyle and medical history that Dr. Insogna and his colleagues review when evaluating a patient’s risk for fracture.

“The unique aspect of our service is that we have decades of experience managing such patients,” Dr. Insogna says. “We know what value there is in having someone who’s an expert in this area interpret those numbers in the context of a particular patient’s clinical history.”

Medications are a double-edged sword

Dr. Insogna and an assistant show a patient the center’s bone densitometry machine.

Treating osteoporosis is tricky because doctors now know that the medications must be administered carefully. Taken for too long or in excessive doses, they can actually harm the skeleton. “It’s much more important now to be more refined in our approach with these patients, because it’s not a free lunch,” says Dr. Insogna.

In McCarthy’s case, he did further testing to determine why she had bone loss at a younger age than most other women who have it. Blood and urine tests eventually revealed that she was not retaining the calcium she was ingesting, partly because a slightly elevated parathyroid hormone level.

For the past three years, Dr. Insogna has been treating McCarthy with an annual infusion of a drug called Reclast. The osteoporosis in her spine has reversed, while osteopenia in other areas has remained the same. Since Reclast can only be administered three times, he is now monitoring her closely every year.

Research holds some promise

The Yale Bone Center team: (seated, l-r): Lorraine J. Collingwood, medical assistant; Gina M. Bejnerowicz, registered technologist; and Kristen A. Martell, clinical receptionist; (standing, l-r): Elizabeth H. Holt, MD, PhD; Dr. Insogna; and Beatrice Lupsa, MD.

Yale doctors hope to improve options in the future for patients like McCarthy. Several years ago, Dr. Insogna and Richard Lifton, MD, PhD, chair of the Department of Genetics at the Yale School of Medicine, were among those to identify a cellular mechanism that explained why some people have high bone density.

Their work led to the development of a drug that Dr. Insogna says holds great promise although it is still in the early stages of development by one and possibly several drug companies. The drug blocks a protein that turns off bone formation. This new drug has been shown to increase bone density in clinical trials.

For the time being, however, prevention remains a very important approach to reducing one’s risk for debilitating fractures due to osteoporosis. Patients at the Yale Bone Center are advised to reduce their risk of falls by making sure their home environment is easy to navigate, having their vision checked and avoiding medications that cause dizziness.

Improving core muscle strength is key particularly to reducing the risk of spine fractures, because the spine is subjected to intense physical forces all the time. Strengthening abdominal and back muscles helps to unload the spine and reduce fracture risk.

Hip fractures are killers with up to 20 percent of patients dying in the first year after a low energy hip fracture. However spine fractures, which are too often ignored, are also very serious. “Spine fractures are very painful,” says Dr. Insogna. “Patients go downhill fast and are very often significantly incapacitated following a vertebral compression. That’s why we want to prevent both hip and spine fractures.”

Story by Jill Max
Photos by Robert Lisak