Osteoporosis

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Contents

Introduction

  • Definitions:
  • low bone mass with a normal ratio of mineral to osteoid
  • generalized skeletal fragility in which bone strength is sufficiently weak that fractures occur with minimal trauma
  • low bone mass & microarchitectural deterioration of bone tissue leading to enhanced bone fragility & consequent increase in fracture risk

Etiology

  • primary (most common)
  • secondary
  • connective tissue disorders
  • pharmacologic causes:

Epidemiology

  • largely, but not exclusively a disease of women
  • osteoporosis manifests itself clinically about 10 years after menopause
  • peak incidence in the 60s & early 70s
  • senile osteoporosis presents after age 70 in either sex
  • 39% of women over 70 have osteoporosis at any site
  • 25% of women over 70 have osteoporosis at the hip
  • 70% of women over 80 have osteoporosis at any site
  • 48% of women over 80 have osteoporosis at the hip

Pathology

Genetics

Clinical-manifestations

Laboratory

  • * serum PTH not needed unless specifially indicated [14]

Radiology

  • screening beginning at age 65 ( USPSTF) & screen women < 65 if their 10-year fracture risk >= that of a woman > 65 without additional risk factors ~ 9% [8]
  • use WHO's FRAX tool to estimate fracture risk
  • not enough evidence to determine whether screening is beneficial or harmful for men [8]
  • recommendations apply to all racial and ethnic groups
  • repeat measurement may be of little benefit in predicting risk of fracture [30]
  • none-the-less, ref [2] recommends repeat DEXA 12-24 months after initiating therapy
  • threshold for treatment may be Z-score of < -1.8

Complications

Management

  • treatment of 63 elderly for 3.5 years to prevent 1 fracture [35]
  • identify & treat sensory deficits, neurologic disease, arthritis
  • adjust doses of sedating drugs
  • gait & balance training
  • environmental measures

More General Terms

Additional Terms

Internet Database

OMIM: 166710

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 499
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
  3. Greenwood G. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. Prescriber's Letter 9(2):8 2002 (subscription needed) [1]
  5. Journal Watch 22(2):11, 2002
    - Siris et al Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286:2815, 2001 PMID: [2]
    - Chesnut CH Osteoporosis, an underdiagnosed disease. JAMA 286:2865, 2001 PMID: [3]
  6. Prescriber's Letter 9(4):20 2002 (subscription needed) [4]
  7. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
  8. Journal Watch 22(22):158, 2002 U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137:526, 2002 PMID: &dopt=Abstract
    - Nelson HD et al, Screening for postmenopausal osteoporosis: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 137:529, 2002 PMID: [5]
    - Nelson HD et al. Screening for osteoporosis: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2010 Jul 20; 153(2):99-111. Epub 2010 Jul 5. Review. PMID: [6]
    - U.S. Preventive Services Task Force Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement Annals of Internal Medicine, January 17, 2011 <PubMed> PMID: [7] <Internet> [8]
  9. Prescriber's Letter 10(1):5 2003
  10. Greenspan SL et al Combination therapy with hormone replacement and alendronate for prevention of bone loss in elderly women: a randomized controlled trial. JAMA 289:2525, 2003 PMID: [9]
  11. National Institutes of Health Osteoporosis and Related bone Diseases - National Resource Center [10]
  12. International Osteoporosis Foundation [11]
  13. National Osteoporosis Foundation [12]
  14. Ferri's Clinical Advisor, Instant Diagnosis and Treatment, Ferri FF (ed), Mosby, Philadelphia, 2003. pg 589
  15. Prescriber's Letter 10(11):65 2003
  16. Journal Watch 24(5):39, 2004 Khaw KT et al Prediction of total and hip fracture risk in men and women by quantitative ultrasound of the calcaneus: EPIC-Norfolk prospective population study. Lancet 363:197, 2004 PMID: [13]
  17. Journal Watch 24(13):104-105, 2004 Miller PD, Barlas S, Brenneman SK, Abbott TA, Chen YT, Barrett-Connor E, Siris ES. An approach to identifying osteopenic women at increased short-term risk of fracture. Arch Intern Med. 2004 May 24;164(10):1113-20. PMID: [14]
    - Siris ES, Chen YT, Abbott TA, Barrett-Connor E, Miller PD, Wehren LE, Berger ML. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. 2004 May 24;164(10):1108-12. PMID: [15]
  18. Prescriber's Letter 11(7):40 2004 Detail-Document#: [16] (subscription needed) [17]
  19. Prescriber's Letter 11(8): 2004 Drugs and Supplements that Cause Bone Loss Detail-Document#: [18] (subscription needed) [19]
  20. Prescriber's Letter 11(11): 64 2004 Carbonated Beverages and Osteoporosis Detail-Document#: [20] (subscription needed) [21]
  21. Journal Watch 24(20):153-154, 2004 Schlienger RG, Kraenzlin ME, Jick SS, Meier CR. Use of beta-blockers and risk of fractures. JAMA. 2004 Sep 15;292(11):1326-32. PMID: [22]
  22. Prescriber's Letter 11(12): 2004 Magnesium Plus Calcium Supplements Detail-Document#: [23] (subscription needed) [24]
  23. Journal Watch 24(24):187, 2004 Ioannidis JP, Ralston SH, Bennett ST, Brandi ML, Grinberg D, Karassa FB, Langdahl B, van Meurs JB, Mosekilde L, Scollen S, Albagha OM, Bustamante M, Carey AH, Dunning AM, Enjuanes A, van Leeuwen JP, Mavilia C, Masi L, McGuigan FE, Nogues X, Pols HA, Reid DM, Schuit SC, Sherlock RE, Uitterlinden AG; GENOMOS Study. Differential genetic effects of ESR1 gene polymorphisms on osteoporosis outcomes. JAMA. 2004 Nov 3;292(17):2105-14. PMID: [25]
  24. Prescriber's Letter 12(2): 2005 Osteoporosis in Men Detail-Document#: [26] (subscription needed) [27]
  25. USPSTF [28]
  26. Journal Watch 25(5):39, 2005 Kern LM, Powe NR, Levine MA, Fitzpatrick AL, Harris TB, Robbins J, Fried LP. Association between screening for osteoporosis and the incidence of hip fracture. Ann Intern Med. 2005 Feb 1;142(3):173-81. PMID: [29]
  27. Prescriber's Letter 12(6): 2005 Calcium and Vitamin D for Reducing Fracture Risk Detail-Document#: [30] (subscription needed) [31]
  28. Marcovitz PA, Tran HH, Franklin BA, O'Neill WW, Yerkey M, Boura J, Kleerekoper M, Dickinson CZ. Usefulness of bone mineral density to predict significant coronary artery disease. Am J Cardiol. 2005 Oct 15;96(8):1059-63. Epub 2005 Aug 22. PMID: [32]
  29. Kahl KG et al, Bone mineral density, bone turnover and osteoprotegerin in depressed women with and without borderline personality disorder Psychosom Med 2006, 68:669 PMID: [33]
  30. Hillier TA, Stone KL, Bauer DC, Rizzo JH, Pedula KL, Cauley JA, Ensrud KE, Hochberg MC, Cummings SR. Evaluating the value of repeat bone mineral density measurement and prediction of fractures in older women: the study of osteoporotic fractures. Arch Intern Med. 2007 Jan 22;167(2):155-60. PMID: [34]
  31. Prescriber's Letter 14(3): 2007 Calcium and Vitamin D Supplementation: Who Needs It? Detail-Document#: [35] (subscription needed) [36]
  32. Orwoll E et al, Alendronate for the treatment of osteoporosis in men. N Engl J Med 2000, 343:604 PMID: [37]
    - Adler RA, The need for increasing awareness of osteoporosis in men. Clinical Cornerstone 2006, 8[suppl 3]:S7-S13 PMID: &dopt=Abstract
  33. Greenspan SL, Bone HG, Ettinger MP, Hanley DA, Lindsay R, Zanchetta JR, Blosch CM, Mathisen AL, Morris SA, Marriott TB; Treatment of Osteoporosis with Parathyroid Hormone Study Group. Effect of recombinant human parathyroid hormone (1-84) on vertebral fracture and bone mineral density in postmenopausal women with osteoporosis: a randomized trial. Ann Intern Med. 2007 Mar 6;146(5):326-39. PMID: [38]
  34. Prescriber's Letter 14(9): 2007 Once-yearly Osteoporosis Treatment and Other Bisphosphonate Developments PATIENT HANDOUT: Bisphosphonates and Jaw Bone Damage INFORMATION FOR DENTISTS: American Dental Association recommendations for patients taking oral bisphosphonates RECLAST FOR OSTEOPOROSIS Detail-Document#: [39] (subscription needed) [40]
  35. Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007 Aug 25;370(9588):657-66. Review. PMID: [41]
  36. Saag KG et al, Tetriparatide or alendronate in glucocorticoid-induced osteoporosis. N Eng J Med 2007, 357:2028 PMID: [42]
  37. Eskandari F et al, Low bone mineral mass in premenopausal women with depression. Arch Intern Med 2007, 167:22329 PMID: [43]
  38. Prescriber's Letter 15(4): 2008 New guideline for prevention and treatment of osteoporosis from the National Osteoporosis Foundation Detail-Document#: [44] (subscription needed) [45]
    - CLINICIAN'S GUIDE TO PREVENTION AND TREATMENT OF OSTEOPOROSIS National Osteoporosis Foundation, 2008 [46]
  39. Liu H, Paige NM, Goldzweig CL, Wong E, Zhou A, Suttorp MJ, Munjas B, Orwoll E, Shekelle P. Screening for osteoporosis in men: a systematic review for an American College of Physicians guideline. Ann Intern Med. 2008 May 6;148(9):685-701. Review. Summary for patients in: Ann Intern Med. 2008 May 6;148(9):I35. <PubMed> PMID: [47] <Internet> [48]
    - Qaseem A et al, Screening for osteoporosis in men: A clinical practive guideline from the American College of Physicians. Ann Intern Med. 2008 May 6;148(9):680-4 <PubMed> PMID: [49] <Internet> [50]
  40. FRAX: WHO Fracture Risk Assessment Tool [51]
  41. Bliuc D et al Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. AMA 2009 Feb 4; 301:513. PMID: [52]
  42. Dreiher J et al. Psoriasis and osteoporosis: A sex-specific association? J Invest Dermatol 2009 Jan 22 <PubMed> PMID: &dopt=Abstract <Internet> [53]
  43. Prescriber's Letter 16(12): 2009 Safety of Long-Term Bisphosphonate Therapy COMMENTARY: Safety of Long-Term Bisphosphonate Therapy GUIDELINES: Prevention and Treatment of Osteoporosis (NOF) GUIDELINES: Diagnosis and Treatment of Osteoporosis (ICSI) GUIDELINES: NAMS Position Statement on the Management of Osteoporosis in Postmenopausal Women GUIDELINES: Prevention and Treatment of Postmenopausal Osteoporosis (AACE) GUIDELINES: Menopause and Osteoporosis Update (Canadian) Detail-Document#: [54] (subscription needed) [55]
  44. Warensjo E et al Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study BMJ 2011; 342:d1473 <PubMed> PMID: [56] <Internet> [57]
  45. Warensjo E et al Dietary calcium intake and risk of fracture and osteoporosis: Prospective longitudinal cohort study. BMJ 2011 May 24; 342:d1473 PMID: [58]
  46. Favus MJ. Bisphosphonates for osteoporosis. N Engl J Med 2010; 363:2027-2035. PMID: [59]
  47. Osteoporosis: NIH Institute and Center Resources [60]
  48. National Guideline Clearinghouse
    - Osteoporosis and bone mineral density. American College of Radiology ngc-guideline: [61]
    - American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. ngc-guideline: [62]
    - Diagnosis and treatment of osteoporosis. (Institute for Clinical Systems Improvement) ngc-guideline: [63]
    - Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. ngc-guideline: [64]
    - Screening for osteoporosis in postmenopausal women: recommendations and rationale. (USPSTF) ngc-guideline: [65]
    - Diagnosis of osteoporosis in men, premenopausal women, and children. (International Society for Clinical Densitometry) ngc-guideline: [66]
    - Osteoporosis: prevention and treatment. (University of Michigan Health System) ngc-guideline: [67]
    - Bisphosphonates (alendronate, etidronate, risedronate), elective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. National Institute for Health and Clinical Excellence ngc-guideline: [68] Osteoporosis. American College of Obstetricians and Gynecologists ngc-guideline: [69]
    - Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. ngc-guideline: [70]
    - Risk factor assessment for osteoporosis and/or increased fracture risk in men. University of Texas, School of Nursing, Family Nurse Practitioner Program. ngc-guideline: [71]
    - Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. American College of Emergency Physicians ngc-guideline: [72]
    - Osteoporosis/fracture prevention clinical practice guidelines Kaiser Permanente Care Management Institute ngc-guideline: [73]
    - Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. American College of Preventive Medicine ngc-guideline: [74]
    - Osteoporosis and fracture prevention in the long-term care setting. American Medical Directors Association ngc-guideline: [75]
    - Denosumab for the prevention of osteoporotic fractures in postmenopausal women. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [76]
    - Osteoporosis: diagnosis, treatment, and fracture prevention. Medical Services Commission, British Columbia ngc-guideline: [77]
    - American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. ngc-guideline: [78] .NATIONAL GUIDELINE CLEARINGHOUSE (NGC), GUIDELINE SYNTHESIS
    - Screening and Risk Assessment for Osteoporosis in Postmenopausal Women a) American College of Preventive Medicine (ACPM). Screening b) North American Menopause Society (NAMS) c) University of Michigan Health System (UMHS) ngc-guideline-synthesis: 35128

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