Brief Overview: Osteoporosis is characterized by low bone mass, microarchitectural disruption, and increased skeletal fragility, resulting in decreased bone strength and increased risk of fracture. Fragility fractures are defined as fractures that occur with low or minimal trauma, such as a fracture resulting from a fall from standing height. The most common sites of fragility fracture are the spine (vertebral compression fractures), hip, and wrist. Fragility fractures also occur at the humerus, rib, and pelvis.
Prevalence:
- Based on bone mineral density (BMD) data from the National Health and Nutrition Examination Survey (NHANES), the prevalence of osteoporosis was 12.6 percent among adults aged 50 years and over in the United States in 2017 to 2018, with a higher prevalence in women (19.6 percent) than in men (4.4 percent). By the age of 85 years, approximately 70 percent of women and over 30 percent of men will have a femoral neck T-score at or below -2.5 (indicating osteoporosis).
- An estimated nine million osteoporotic fractures occurred worldwide in 2000.
Etiology: In adults, the daily removal of small amounts of bone mineral, a process called resorption, is balanced by an equal deposition of new mineral to maintain bone strength. When this balance tips toward excessive resorption, bones weaken and over time can become brittle and prone to fracture (osteoporosis). There are many conditions, medications, and factors that can lead to osteoporosis.
Risk Factors:
- Advanced age
- Females > males
- Postmenopausal state
- Previous fracture
- Certain medications can increase risk like: Glucocorticoid medications, heparin, certain antiseizure medications, aromatase inhibitors (for treatment of breast cancer)
- Parental history of hip fracture
- Low body weight
- Current cigarette smoking
- Excessive alcohol consumption
- Physical inactivity
- Poor nutrition
- Rheumatoid arthritis
- Secondary osteoporosis (eg, hypogonadism or premature menopause, malabsorption, chronic liver disease, inflammatory bowel disease)
Commonly Associated Conditions: There are many conditions associated with, or that can cause, osteoporosis, including but not limited to:
- Medications – antiseizure medications (particularly phenobarbital and phenytoin), aromatase inhibitors, cancer chemotherapy, glucocorticoids, GnRH agonists and antagonists, Heparin, immunosuppressants (cyclosporine)
- Endocrine disorders: acromegaly, adrenal insufficiency, cushing syndrome, diabetes mellitus, eating disorders, endometriosis, hyperparathyroidism, hyperprolactinemia, hyperthyroidism, hypogonadism (primary or secondary)
- GI Disease/Nutritional Disorders: alcohol-related liver disease, celiac disease, chronic active hepatitis, chronic cholestatic disease, gastrectomy, inflammatory bowel disease, jejunoileal bypass, malabsorption syndromes, pancreatic insufficiency, parenteral nutrition, primary biliary cholangitis, severe liver disease, vitamin D and/or calcium deficiency
- Marrow-related disorders: amyloidosis, hemochromatosis, hemophilia, leukemia, lymphoma, mastocytosis, monoclonal gammopathy of undetermined significance, multiple myeloma, pernicious anemia, sarcoidosis, sickle cell anemia, thalassemia
- Organ transplantation: bone marrow, heart, liver, kidney, lung
- Miscellaneous causes: ankylosing spondylitis, COPD, epidermolysis bullosa, idiopathic hypercalciuria, multiple sclerosis, rheumatoid arthritis
- Genetic disorders: homocystinuria due to cystathionine deficiency, hypophosphatasia, osteogenesis imperfecta
Common Medications:
- Bisphosphonates (some common options are: alendronate, risedronate, zoledronic acid, ibandronate)
- Testosterone therapy for men when indicated
- Hormone therapy may be indicated for some women
- Anabolic agents or denosumab may be prescribed in bisphosphonates are contraindicated
- Other pharmacological therapies may be prescribed or chosen based on patient’s specific needs
Common Labs, Imaging, and Tests:
- DEXA scan
- 25-hydroxyvitamin D
- Calcium, phosphorous
- CBC
- CMP (including alkaline phosphatase)
- Additional lab tests may be indicated
Common Symptoms:
- Osteoporosis has no clinical manifestations until there is a fracture
Common Treatments:
- Medications (see above)
- Lifestyle modifications: weight-bearing exercises (if safe and appropriate), smoking and excessive alcohol intake should be avoided
- Counseling on fall prevention
- Calcium and Vitamin D supplementation may be recommended by healthcare provider
- Management of underlying conditions
- Diet recommendations for skeletal health may be given by healthcare provider
Physical Findings:
- Osteoporosis has no clinical manifestations until a fracture occurs
- Vertebral fracture is the most common clinical manifestation of osteoporosis. Most of these fractures (approximately two-thirds) are asymptomatic; they are diagnosed as an incidental finding on chest or abdominal radiograph
- Hip fractures are relatively common in osteoporosis, affecting up to 15 percent of women and 5 percent of men by 80 years of age. In addition, distal radius fractures (Colles fractures) may occur. Colles fractures are more common in women shortly after menopause, whereas the risk of hip fracture increases exponentially with age
Potential Complications and Contraindications:
- Fractures
- Pain, disability
- Decreased independence, increased fall risk
- Oral bisphosphonates should not be used as initial therapy in patients with esophageal disorders (achalasia, scleroderma involving the esophagus, esophageal strictures), an inability to follow the dosing requirements (eg, stay upright for at least 30 to 60 minutes), or advanced chronic kidney disease (CKD; estimated glomerular filtration [eGFR] rate <30 mL/min/1.73 m2) (algorithm 2). Oral bisphosphonates also should be avoided after certain types of bariatric surgery in which surgical anastomoses are present in the gastrointestinal tract (eg, Roux-en-Y gastric bypass).
- Patients who are allergic to bisphosphonates or who develop severe bone pain with them require an alternative treatment
General Health and Lifestyle Guidance:
- Fall prevention – adequate lighting, appropriate footwear, clear walkways, secure rugs and mats, install grab bars/handrails as needed, non-slip mats, keep frequently used items within reach, mobility aids as needed
- Weight-bearing exercise if safe and appropriate – discuss any new exercise regimen with your healthcare provider
- Smoking cessation
- Avoid excessive alcohol consumption
- Carry a mobile phone or wear a medical alert device so that you can quickly and easily call for emergency help if needed
Suggested Questions to Ask Patients:
- Have you ever had a bone density test?
- Have you had any fractures from a minor fall or injury?
- Has your healthcare provider recommended calcium or vitamin D supplements?
- How is your balance and mobility at home?
- Do you have any conditions or medications that could affect your bone health?
Suggested Talking Points:
- Osteoporosis is asymptomatic prior to a fracture. A bone density scan can help understand your risk
- Strengthening your bones now can help prevent fractures later
- Ways to make your home safer and reduce your risk of falling
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