Resumen
Puntos para una lectura rápida
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La disminución de la densidad mineral ósea es un factor de riesgo de fractura más, no un criterio de enfermedad. La edad es el factor de riesgo más importante (siete veces más que el descenso de la DMO en fractura de cadera).
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La estrategia de realizar un cribado poblacional en mayores de 50 años no se sustenta. La mayoría de las sociedades científicas asumen la estrategia de valorar el riesgo de fractura en los próximos 10 años con escalas validadas y calibradas. La escala FRAX es la más ampliamente utilizada.
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Una estrategia para calibrar el riesgo y determinar los umbrales de intervención y tratamiento válida para nuestro entorno es la propuesta en 2015 por la DGFCM (diseñada con datos de fractura de cadera de la Comunidad de Madrid). El modelo propone valorar el riesgo de fractura de cadera en los próximos 10 años en función de la edad y de la puntuación de riesgo individual de la paciente. En mujeres con riesgo>10% recomiendan tratamiento sin necesidad de densitometría y en mujeres con riesgo<3% desaconsejan hacer ninguna intervención. En mujeres de riesgo intermedio (10-3%), recomiendan solicitar densitometría como prueba discriminante, valorando la indicación de tratamiento según la Z-score obtenida en la misma.
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No hay evidencia de eficacia de los tratamientos antifractura ni en prevención primaria ni en mujeres con densitometría en rango osteopénico: las poblaciones de los estudios de los distintos fármacos eran mujeres con AP de fracturas o <-2DS de T-score. Los fármacos han demostrado eficacia en fractura vertebral, pero hay escasa evidencia de su eficacia en fractura de cadera.
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No existen estudios en prevención primaria en mujeres<65 años, por lo que en ellas el riesgo debe ser individualizado. Asimismo, la decisión de tratar a mujeres>80 años debe ser también individualizada por su situación de pluripatología y polifarmacia.
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Los fármacos de primera elección son el alendronato (10mg/día o 70mg/semana VO) o risedronato (5mg/día, 35mg/s o 75mg/mes VO), que deben administrarse con suplementos de vitamina D (400-800 UI/día) y calcio (0,5-1,2g/día). El tratamiento no debe superar los 5 años de duración y el seguimiento de las pacientes ha de ser anual mediante la reevaluación clínica de las mismas (presencia de nuevos factores de riesgo o de nuevas fracturas osteoporóticas).
Palabras clave
Osteoporosis
Grupos de riesgo
Terapéutica
Uso excesivo de los servicios de salud.
Identifíquese
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