Osteoporosis
Claire Lo
Background
- Definition: decreased bone mass leading to increased risk of fracture.
- Differential: malignancy (e.g., multiple myeloma), elder abuse (e.g., spiral fractures of long bones), hyperparathyroidism, Paget’s disease.
Post-Menopausal Women | Pre-Menopausal Women | |
|---|---|---|
| Risk Factors | current smoker, >3 alcoholic drinks/day, chronic glucocorticoids (>4 weeks), previous fracture, parental history of fracture, RA, low-weight bearing status | Female Athlete Triad (disordered eating, amenorrhea, bone loss) |
| Presentation | height loss, fragility fracture (GLF, minor trauma) | repetitive long bone stress fractures, atypical fractures (pubic ramus, femoral neck, non-metatarsal foot bones) |
| Screening | all women 65yo+ (Grade B USPSTF) | women<65yo w/ clinical risk factors (Grade B USPSTF) |
| Tests | Gold Standard: DEXA hip and lumbar spine Labs: 25[OH]D, calcium, phos, albumin, total protein, LFTs (ALP), PTH | |
| Diagnosis | T score ≦ -2.5 at femoral neck or spine OR fragility fracture of vertebra, femur, pelvis, wrist, humerus, rib | |
| Management | vitamin D supplementation, calcium if necessary, smoking cessation, weight bearing activity, Rx | |
| Monitoring | DEXA q2 years (for osteoporosis), q4 years (for osteopenia), q15 years (for normal BMD). | |
Evaluation
- Interpretation of DEXA Score
- Osteoporosis: T score ≦ -2.5
- Osteopenia: -1.0 > T score > -2.5
- Normal bone mineral density: T score < -1.0.
- Interpretation of FRAX (Fracture Risk Assessment Tool) used for risk stratification in osteopenia:
- 10-year risk of major osteoporotic fracture for hip fracture (Google “FRAX tool.”)
Pharmacologic Management
- Indications: T score ≦ -2.5 (osteoporosis) OR -1.0 > T score > -2.5 with FRAX>3% for hip fracture or >20% for major osteoporotic fracture.
- First line: oral bisphosphonates (alendronate 70mg weekly, at least 30min before food). Can also consider IV bisphosphonate (yearly Reclast) for patient convenience.
- If CrCl <35: refer to endocrinology for alternative options.
- If severe (T score< -3.0 or fragility fracture): consider anabolic (e.g., teriparatide, abaloparatide, or romosozumab) as first line agent.
Additional Information
- There is currently no recommendation to screen men for osteoporosis.