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Screening for Bone Fracture Risk Should Be Routine for HIV+ People over 40

Screening for fracture risk should be a routine part of HIV care for all people over 40, and all postmenopausal women, all men over 50, and people at high risk for fractures of any age should undergo DEXA screening (a type of X-ray) to assess bone mineral density and their need for treatment, experts on bone disorders recommend in new guidelines published in the January 21 online edition of Clinical Infectious Diseases.

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Low bone mineral density and fragility fractures occur more frequently among people living with HIV than other people of a similar age. Several studies conducted in U.S. men and women living with HIV have shown that the rate of fractures of the spine, hip, and wrist is approximately 60% higher than in the general population.

It is unclear whether HIV causes bone mineral loss, also known as osteopenia or osteoporosis, but bone mineral density usually declines by 2%-6% in the first 2 years after starting antiretroviral treatment. People living with HIV also tend to have a high frequency of risk factors for osteoporosis including smoking, high alcohol consumption, low body weight, and poor nutrition. As the population of people living with HIV ages, bone loss is becoming a more serious problem.

International guidelines for management of bone loss were developed by 34 experts from 16 countries. Their recommendations cover screening, diagnosis and monitoring of bone disease and are graded accorded to the strength of evidence available.

Screening and Risk Assessment

Without screening to identify people at high risk of fractures, it is not possible to provide preventive treatment. The expert panel made several recommendations.

People at high risk of fragility fractures should undergo DEXA screening. Fragility fractures are broken bones that occur without major trauma, for example when falling, and most commonly involve the wrist, arm, shoulder, hip, or spine. People at high risk are those with a previous history of fragility fractures, those at high risk of falls, and people treated with glucocorticoids for at least 3 months. All postmenopausal women, all people with major risk factors for fragility fractures, and men age 50 or over should undergo DEXA screening too.

Men age 40-49 and premenopausal women age 40 and over can be assessed for fracture risk if they lack a major risk factor by using the FRAX scoring system (based on the person’s lifestyle and medical history) every 3 years, without the need for DEXA screening. Anyone in these groups with a 10-year fracture risk above 10% should undergo DEXA screening. Repeat screening should be considered 1 to 2 years later for people who have advanced osteopenia, and after 5 years for mild-to-moderate cases of osteopenia.

The recommendations emphasize that where DEXA screening is not easily available, FRAX scoring should be used to identify people at high risk of fracture.

Minor vertebral fractures, described by doctors as subclinical, can occur without major effects on mobility and may go unrecognized despite causing chronic pain. They are a strong risk factor for future fractures. Height should be measured every 1 to 2 years in adults age 50 and over, and DEXA or X-ray screening is recommended for women age 70 and over and men age 80 and over if there is evidence of osteopenia. It is also recommended in people over 50 who have lost 4 cm in height, suffered a fragility fracture, or undergone recent glucocorticoid treatment.

Antiretroviral Treatment

Starting antiretroviral treatment is associated with a 2%-6% loss in bone mineral density during the first 2 years. There is evidence that tenofovir (Viread, also in Truvada and several single-tablet regimens) and boosted protease inhibitors cause greater bone loss compared to other drugs. Alternative regimens should be discussed with patients who have low bone mineral density or osteoporosis. The authors of the guidelines say that well-designed trials are needed to test the impact of integrase inhibitors on bone mineral density during first-line treatment.

Preventing Fragility Fractures

Dietary and lifestyle changes are the first line of protection against fractures. Men age 50-70 at risk of fractures should aim to get 1000 mg of calcium per day, and men age 70 and over and women over 50 should aim to get 1300 mg per day. (Review the International Osteoporosis Foundation’s checklist of the calcium content of foods here). Calcium supplements may be needed if it is not possible to get the recommended intake from the daily diet.

Vitamin D levels are often low in people living with HIV, and these should be measured in people with low bone mineral density or a history of fractures. Vitamin D deficiency may lead to hyperparathyroidism (excess production of parathyroid hormone), which damages bone. Vitamin D supplementation should aim to maintain 25(OH)D levels above 30 ng/mL.

People living with HIV who have osteoporosis will benefit from weight-bearing and muscle-strengthening exercises, stopping smoking, and reducing alcohol consumption, the guidelines recommend.

Medication to prevent osteoporosis should be administered according to national guidelines. Alendronate (Fosamax) 70 mg once-weekly has been shown to increase bone mineral density in people with HIV, but if it proves unsuccessful, intravenous zoledronic acid (Zometa) once yearly may be considered, the guidelines recommend.

2/11/15

Reference

TT Brown, J Hoy, M Borderi, et al. Recommendations for Evaluation and Management of Bone Disease in HIV. Clinical Infectious Diseases. January 21, 2015 (Epub ahead of print).