stroke, and checking BMD

A brief report looked at the frequency of screening and treatment of osteoporosis after a stroke (see stroke bone density stroke2019 in dropbox, or DOI: 10.1161/STROKEAHA.118.024685)

Details:

-- Data-mining from the Ontario Stroke Registry of patients >65 yo seen at one of 11 regional stroke centers in Ontario, linked to physician claims database to identify those who had bone mineral density testing (BMD) or medication prescriptions for fracture prevention within one year post-stroke, from 2003-2013

-- exclusions: those in long-term care facilities

-- 16,581 patients identified: 77% female, 78 yo, 88% ischemic stroke/12%intracerebral hemorrhage, severe stroke 13%/moderate 20%/mild 67%, prior fracture 10%, prior BMD 27%, prior osteoporosis med 18%, dementia 15%

-- 1-yr outcomes after stroke:

    -- fracture rate 4%

    -- falls 10%

    -- mortality 20%

Results:

-- 846 (5.1%) had a BMD done, and 2575 (15.5%) had osteoporosis therapy prescribed

-- only 2.9% had a BMD, if one excludes those with a history of prior BMD testing

-- of those not previously put on osteoporosis meds, meds were prescribed in 3.2% of the overall cohort, in 7.8% of those with pre-stroke fractures, and meds were prescribed in only 14.8% of those with post-stroke fractures

-- in those who had not had BMD testing in the prior 5 years, the rate of poststroke BMD was higher in those who were younger, female, and had low-trauma fractures in the year poststroke

-- stroke severity and comorbid conditions were not associated with poststroke osteoporosis screening or treatment (comorbidities included renal disease, hypertension, diabetes, peripheral arterial disease, pulmonary edema, atrial fibrillation, dementia, depression, cancer, rheumatoid arthritis, hyperparathyroidism, malabsorption syndromes, and Parkinson’s disease)

Commentary:

-- screening rates with BMD in the US are quite low in those recommended for screening, around 27% overall, and as low as 30% even in high risk groups

-- stroke is a significant risk factor for osteoporosis, falls, and fractures

    -- the risk of fractures in the year after stroke is 3 to 10%, a fourfold increased risk compared to healthy controls

-- the increased risk of fractures after a stroke has been attributed to reduced mobility and resultant accelerated decline in BMD, as well as increased risk of falls

-- it is notable that US stroke guidelines recommend fall prevention strategies, without explicitly recommending BMD testing and treatment. They do note that 70% of patients with a stroke fall during the first 6 months after discharge from a hospital or rehab (!!!), but recommend only that patients be involved in exercise programs, tai chi, fall prevention programs, and environmental modifications to decrease the fall risk (see stroke rehab guidelines stroke2016 in dropbox, or Winstein CJ. Stroke29016; 47: e98)

-- the general osteoporosis screening guidelines for those over 65 yo do recommend BMD screening, as well as in selected men and younger adults (ie, by these guidelines alone, all of these stroke patients should have been screened!!)

--Medicare claims data suggest that the incidence of hip fractures has been higher than anticipated (11,464 more hip fractures than predicted over a recent 11 time period, with 2293 more deaths within one year of the hip fracture), see http://gmodestmedblogs.blogspot.com/2018/02/osteoporotic-fractures-going-wrong-way.html

-- and, remarkably few patients (7%) who had an osteoporotic hip fracture were put on osteoporosis meds, despite their quite high recurrent fracture risk (15 to 25% have a 2^nd fracture within 10 years), see http://gmodestmedblogs.blogspot.com/2018/07/decreasing-use-of-osteoporosis-meds.html

-- the reasons why we are prescribing fewer osteoporosis medications is likely related to the FDA’s safety announcements about bisphosphonates leading to atypical femoral fractures, osteonecrosis of the jaw, and atrial fibrillation. As noted in the blog http://gmodestmedblogs.blogspot.com/2018/07/decreasing-use-of-osteoporosis-meds.html , a larger meta-analysis did not confirm a higher rate of atrial fibrillation, and the incidence of osteonecrosis of the jaw and atypical femoral fractures is quite low as compared to the incidence/morbidity/mortality from regular osteoporotic fractures, many of which may have been prevented if meds had been prescribed

So, the bottom line is that we are probably not doing sufficient BMD screening overall, and this is even more of an issue in high risk people such as those with a recent stroke. There certainly are other important medical issues for us to address in the early poststroke period, but this issue really does bubble up to the top as a really important one to help prevent a potentially quite debilitating or mortal event in this very high risk group.

geoff​

If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org

to get access to all of the blogs:

1. go to http://gmodestmedblogs.blogspot.com/ to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category​

3. or you can just click on the magnifying glass on top right, then type in a name in the search box and get all the blogs with that name in them

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list