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Osteoporosis

Last updated: February 3, 2021

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Osteoporosis is a skeletal condition in which the loss of bone mineral density leads to decreased bone strength and an increased susceptibility to fractures. The disease typically affects postmenopausal women and the elderly, as an abrupt decrease in estrogen and age-related processes play a key role in the development of osteoporosis. Further risk factors include inactivity, smoking, and alcohol consumption. Osteoporosis usually remains asymptomatic until the first occurrence of fragility fractures (following minor trauma), particularly of the vertebrae. After repeated vertebral fractures, patients may also develop thoracic hyperkyphosis and lose height. Osteoporosis is diagnosed through a bone density test (dual-energy x-ray absorptiometry), while fractures are usually confirmed through conventional x-ray. Management of osteoporosis includes prophylactic measures and medical therapy. The prophylaxis consists mainly of adequate intake of calcium and vitamin D and regular physical activity with strengthening exercises. Both help to maintain or even increase bone mass and improve balance, thereby reducing the risk of falling. Medical therapy is indicated in cases of severely reduced bone density or osteoporotic fractures. The most commonly used drugs are bisphosphonates, which inhibit bone resorption and can significantly decrease the risk of fractures. There are several other possible medical therapies (e.g., teriparatide, raloxifene), which may be indicated in special cases (e.g., severe osteoporosis, breast cancer prophylaxis required) or if patients have contraindications to bisphosphonates.

  • Osteoporosis: loss of trabecular and cortical bone mass which leads to bone weakness and increased susceptibility to fractures
  • Osteopenia: decreased bone strength but less severe than osteoporosis
  • Sex: > (∼ 4:1)
  • Age of onset: 50–70 years
  • Demographics: higher incidence in individuals of Asian, Hispanic, and northern European ancestry [1]

Epidemiological data refers to the US, unless otherwise specified.

Imaging

DXA (dual-energy x-ray absorptiometry)

Osteoporosis is diagnosed if T-score ≤ -2.5 SD and/or a fragility fracture is present.

Plain radiography

  • If osteoporosis is diagnosed: Radiographic assessment of the whole skeletal system is recommended, particularly if a fracture is already suspected or height loss has occurred.
  • Increased radiolucency is detectable in cortical bones once 30–50% of bone mineral has been lost [13]
  • Osteoporosis can be diagnosed if vertebral compression fractures are present ; commonly an incidental finding because such fractures are typically asymptomatic.

Quantitative computed tomography (QCT) [14]

Used for the measurement of true bone volume density in g/cm3

Clinical chemistry

Usually normal findings, but some markers may be used for assessing the risk of fracture . See “Laboratory evaluation of bone disease” for more information.

Pathology

  • Thin, disconnected trabecular structures
  • Attenuated, pitted cortical bone
  • Increased osteoclast number and activity

The differential diagnoses listed here are not exhaustive.

Medical therapy [17]

Indications

Drug of choice

Bisphosphonates should be taken in the morning and evening at least 30 minutes before meals, with plenty of water, and the patient should maintain an upright position for at least 30 minutes following intake to prevent esophagitis. [19]

Alternative drugs [9]

Used in the case of contraindications/unresponsiveness to bisphosphonates.

Denosumab makes you dance.

  • Diet
  • Physical activity: with strength and balance training
  • Drug intake: Avoid or minimize use of glucocorticoids.
  1. Percentage of Adults Aged 65 and Over With Osteoporosis or Low Bone Mass at the Femur Neck or Lumbar Spine: United States, 2005–2010. https://www.cdc.gov/nchs/data/hestat/osteoporsis/osteoporosis2005_2010.htm. . Accessed: November 6, 2020.
  2. Riggs BL, Khosla S, Melton LJ 3rd.. A unitary model for involutional osteoporosis: estrogen deficiency causes both type I and type II osteoporosis in postmenopausal women and contributes to bone loss in aging men.. Journal of Bone and Mineral Research. 1998; 13 (5): p.763-73.
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  6. Rosen HN, Rosen CJ, Mulder JE. Pathogenesis, clinical features, and evaluation of glucocorticoid-induced osteoporosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pathogenesis-clinical-features-and-evaluation-of-glucocorticoid-induced-osteoporosis.Last updated: July 8, 2016. Accessed: December 6, 2016.
  7. MEDICATIONS THAT CAN CAUSE BONE LOSS, FALLS AND/OR FRACTURES. https://osteoporosis.ca/about-the-disease/what-is-osteoporosis/secondary-osteoporosis/medications-that-can-cause-bone-loss-falls-andor-fractures/. . Accessed: February 3, 2021.
  8. Rogerson D. Vegan diets: practical advice for athletes and exercisers. J Int Soc Sports Nutr. 2017; 14 (1). doi: 10.1186/s12970-017-0192-9 . | Open in Read by QxMD
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  10. Rosen HN, Drezner MK, Rosen CJ, Schmader KE, Mulder JE. Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-in-postmenopausal-women.Last updated: May 27, 2016. Accessed: December 6, 2016.
  11. Lewiecki EM, Rosen CJ, Mulder JE. Overview of dual-energy x-ray absorptiometry. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-dual-energy-x-ray-absorptiometry.Last updated: October 21, 2015. Accessed: December 6, 2016.
  12. Uptodate. Osteoporosis screening recommendations. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/image?imageKey=ENDO%2F62866&topicKey=ENDO%2F2046&rank=2~150&source=see_link&search=osteoporosis.Last updated: January 1, 2016. Accessed: December 6, 2016.
  13. Guglielmi G, Muscarella S, Bazzocchi A. Integrated Imaging Approach to Osteoporosis: State-of-the-Art Review and Update. RadioGraphics. 2011; 31 (5): p.1343-1364. doi: 10.1148/rg.315105712 . | Open in Read by QxMD
  14. Brett AD, Brown JK. Quantitative computed tomography and opportunistic bone density screening by dual use of computed tomography scans. Journal of Orthopaedic Translation. 2015; 3 (4): p.178-184. doi: 10.1016/j.jot.2015.08.006 . | Open in Read by QxMD
  15. Paul T, Shetty S, Kapoor N, Bondu J, Thomas N. Bone turnover markers: Emerging tool in the management of osteoporosis. Indian Journal of Endocrinology and Metabolism. 2016; 20 (6): p.846. doi: 10.4103/2230-8210.192914 . | Open in Read by QxMD
  16. Lee J, Vasikaran S. Current Recommendations for Laboratory Testing and Use of Bone Turnover Markers in Management of Osteoporosis. Annals of Laboratory Medicine. 2012; 32 (2): p.105-112. doi: 10.3343/alm.2012.32.2.105 . | Open in Read by QxMD
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  18. Kennel KA, Drake MT. Adverse Effects of Bisphosphonates: Implications for Osteoporosis Management. Mayo Clinic Proceedings. 2009; 84 (7): p.632-638. doi: 10.1016/s0025-6196(11)60752-0 . | Open in Read by QxMD
  19. Ganesan K, Bansal P, Goyal A, Roane D. Bisphosphonate. StatPearls. 2020 .
  20. Uptodate. Raloxifene: Drug information. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/raloxifene-drug-information?source=see_link.Last updated: January 1, 2016. Accessed: December 6, 2016.
  21. McLaughlin MB, Jialal I. Calcitonin. StatPearls. 2020 .
  22. Golds G, Houdek D, Arnason T. Male Hypogonadism and Osteoporosis: The Effects, Clinical Consequences, and Treatment of Testosterone Deficiency in Bone Health. International Journal of Endocrinology. 2017; 2017 : p.1-15. doi: 10.1155/2017/4602129 . | Open in Read by QxMD