Osteoporosis and Fractures Are Common, and Becoming More So
• About 10 million Americans age >50 years have osteoporosis1
• Almost 34 million more have osteopenia1
• In 2005, >2 million osteoporotic fractures were sustained, costing an estimated $17 billion2
• As the population continues to age, the incidence and prevalence will increase1
– By 2020, 1 in 2 Americans older than age 50 years will have, or be at risk of, developing osteoporosis of the hip1
– By 2025, the number of fractures is expected to increase to >3 million at an estimated cost of $25.3 billion every year2
1. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004. 2. Burge R, et al. J Bone Miner Res. 2007;22:465-475.
Osteoporotic Fractures Are Associated with Increased Mortality
With permission from Bluic D, et al. JAMA. 2009;301:513-521.
“Red Flags” that Warrant Further Assessment
• Prior low-trauma fracture as an adult
• Family history of osteoporosis, especially parental history of hip fracture
• Weight loss of >1%/year in the elderly
• Treatment with drugs that adversely affect bone metabolism
• Disease or conditions linked to secondary osteoporosis
• Unusual cessation of menstrual periods
• Anorexia nervosa (marked weight reduction)
• Athletic amenorrhea syndrome related to intense physical activity
US Department of Health and Human Services. Bone Health and Osteoporosis:A Report of the Surgeon General. Rockville, MD: 2004.
Endocrine Disease or Metabolic Causes
Nutritional Conditions Drugs
Disorders of Collagen
Metabolism Other
Hypogonadism
Cushing’s syndrome
Hyperthyroidism
Hyperparathyroidism
Anorexia nervosa
Hyperprolactinemia
Porphyria
Hypophosphatasia
Diabetes mellitus, type 1
Acromegaly
Malabsorption syndromes (eg, celiac disease)
Malnutrition
Chronic cholestatic liver disease
Gastric operations
Vitamin D deficiency
Calcium deficiency
Alcoholism
Hypercalciuria
Glucocorticoids
Medroxyprogesterone
Excess thyroid hormone
Heparin
Antiepileptics
Gonadotropin- releasing hormone analog agonists
Aromatase inhibitors
Thiazolidinedione drugs
Selective serotonin reuptake inhibitors
Proton pump inhibitors
Osteogenesis imperfecta
Homocystinuria
Ehlers-Danlos syndrome
Marfan syndrome
Chronic obstructive pulmonary disease
Rheumatoid arthritis
Myeloma, leukemia, lymphoma
Immobilization
Renal tubular acidosis
Organ transplantation
Mastocytosis
Thalassemia
AACE Osteoporosis Guidelines. Endocr Pract. 2003;9:544-564. With permission from the American Association of Clinical Endocrinologists.
Selected Secondary Causes of Osteoporosis in Adults
Who Should Have BMD Screening?
The National Osteoporosis Foundation recommends BMD screening for:
• Women age ≥65 years and men age ≥75 years, regardless of risk factors
• Younger postmenopausal women, women in the menopausal transition, and men age 50–70 years if they have risk factors associated with increased fracture risk
• Adults with a previous fracture after age 50
• Anyone at risk for secondary osteoporosis
• Anyone receiving osteoporosis treatment, to monitor treatment effect
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation . Washington, DC: National Osteoporosis Foundation; 2002:1-55.
Osteoporosis DefinedBased on DXA Measurement of BMD
Normal BMD within 1 SD of young normal adult
(T-score ≥-1.0)
Osteopenia
(low bone mass)
BMD 1.1–2.49 SD below young normal adult (T-score -1.1 to -2.49)
Osteoporosis BMD ≥2.5 SD below young normal adult
(T-score ≤-2.5)
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.
FRAX—Fracture Risk Assessment Toolwww.shef.ac.uk/FRAX
• Estimates absolute 10-year risk of a hip fracture or major osteoporotic fracture (ie, vertebral, hip, forearm, humerus)1
• Incorporates clinical risk factors for fracture2,3
– Age
– Gender
– Previous fragility fracture after age 50 years
– History of glucocorticoid use
– Parental history of hip fracture
– Rheumatoid arthritis
– Secondary osteoporosis
– Current smoker
– Alcohol consumption >3 drinks per day
– Body mass index
• More sensitive than bone mineral density alone in identifying those at high risk of fracture2
• Pertains only to previously untreated patients1
1. National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55. 2. American College of Rheumatology Hotline summary of FRAX. March 18, 2008. 3. FRAX. WHO Fracture Risk Assessment Tool. 2008. www.shef.ac.uk/FRAX. Accessed April 21, 2009.
Primary Prevention for All Patients
• Well-balanced nutrition– Calcium = at least 1200 mg/day
– Vitamin D = 800 to 1000 mg/day
• Active, healthy lifestyle– Regular weight-bearing and muscle-strengthening exercise
Improves agility, posture, and balance
May provide modest increases in bone density
– Avoid or stop cigarette smoking
– Avoid or stop excessive alcohol consumption (>3 drinks/day)
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.
Fall Prevention Strategies
• Falls frequently cause fractures; preventing falls helps prevent fractures
• Address risk factors for falls– Environmental factors: low lighting, obstacles in the
walking path, lack of assist devices in the bathroom
– Medical factors: poor vision, previous fall, orthostatic hypotension, medications that may affect balance or cause sedation
• Consider muscle strengthening and balance retraining
US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004.
Pharmacologic Therapy in Primary Prevention
Antiresorptive Agent
MOA: reduce bone loss
• Bisphosphonates
– Alendronate
– Ibandronate
– Risedronate
– Zoledronate
• Estrogen
• Raloxifene
• Calcitonin
Anabolic Agents
MOA: build bone
• Parathyroid hormone– Teriparatide
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.
Monitoring Patients on Pharmacotherapy
• Assess adherence to therapy and lifestyle modifications
• Continue to evaluate and address risk factors for falls
• Measure bone mineral density every 2 years in patients on pharmacotherapy – Monitoring with DXA should be in accordance with medical
necessity, expected response, and in consideration of local regulatory requirements
– Use consistent DXA instrument, facility, and personnel for repeat monitoring
• Consider measurement of biochemical markers of bone turnover in patients whose bone density has decreased despite treatment compliance; evaluate for other secondary causes of bone loss
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.
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