Abstract
Osteopenia and osteoporosis are common skeletal disorders characterized by decreased bone mass, disruption of bony microarchitecture with loss of trabeculae, diminished bone strength, and an increased risk of fracture. Both conditions arise from inadequate bone development/deposition, excessive bone breakdown, or a combination of both. In the vast majority of cases, osteoporosis is a natural consequence of aging, though a number of other causative factors have been identified. Bone mineral density testing via central dual-energy x-ray absorptiometry (DEXA) remains the cornerstone of osteoporosis diagnosis and assessment of response to treatment. The management of osteoporosis is multifactorial and includes a combination of lifestyle modifications, nutritional counseling, and pharmacologic interventions with oral or IV bisphosphonates and teriparatide having been shown to be most efficacious in increasing bone mineral density and decreasing future fracture risk.
Key Concepts
- •
Osteopenia and osteoporosis are common skeletal disorders characterized by decreased bone mass, disruption of bony microarchitecture with loss of trabeculae, diminished bone strength, and an increased risk of fracture.
- •
Both conditions arise from inadequate bone development/deposition, excessive bone breakdown, or a combination of both.
- •
Relative estrogen deficiency in pre-menopause or frank estrogen deficiency in postmenopause are important causative factors, as estrogen plays a central role in skeletal homeostasis and bone mineral density (BMD).
- •
In the vast majority of cases, osteoporosis arises as a natural consequence of aging, though a number of other causative factors may impact overall bone health ( Box 19.1 ).
Box 19.1
Secondary Causes of Osteoporosis
Endocrine
Adrenal insufficiency
Cushing syndrome
Eating disorders
Endometriosis
Hyperparathyroidism
Hyperprolactinemia
Hyperthyroidism
Hypogonadism
Diabetes Mellitus
Gastrointestinal/Nutrition
Inflammatory bowel disease
Vitamin D and/or calcium deficiency
Anorexia nervosa
Celiac disease
Malabsorption syndromes
Pancreatic insufficiency
Marrow Disorders
Hemochromatosis
Leukemia
Lymphoma
Mastocytosis
Multiple myeloma
Pernicious anemia
Miscellaneous Causes
Ankylosing spondylitis
Idiopathic hypercalciuria
Idiopathic scoliosis
Multiple sclerosis
Rheumatoid arthritis
- •
Based on World Health Organization (WHO) criteria (see the following), 20-30% of postmenopausal women in the United States have osteoporosis, with more than 1.3 million fractures per year attributable to the disease.
- •
Using the same criteria, it is estimated that 1 to 2 million men have osteoporosis and 8 to 13 million men have osteopenia.
History
- •
Osteoporosis is considered a “silent disease” until an insufficiency fracture occurs.
- •
The National Osteoporosis Foundation has established guidelines to aid practitioners in identifying patients for whom BMD testing is appropriate ( Box 19.2 ).
Box 19.2
Who Should Be Tested
National Osteoporosis Foundation
- •
All women aged 65 and older regardless of risk factors
- •
Younger postmenopausal women with one or more risk factor(s) (other than being white, postmenopausal, and female)
- •
Postmenopausal women who are considering therapy if bone mineral density testing would facilitate the decision
- •
Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity)
- •
- •
Assessment of clinical risk factors ( Box 19.3 ) is an important starting point in evaluating a patient with low BMD; the most readily recognized risk factors are increasing age and female gender.
Box 19.3
Risk Factors for Osteoporotic Fractures
Major Risk Factors in White Women
- •
Personal history of fracture as an adult
- •
History of fragility fracture in a first-degree relative
- •
Low body weight (<127 pounds)
- •
Current smoking
- •
Use of oral corticosteroid therapy for >3 months
Additional Risk Factors
- •
Premature menopause (<45 years)
- •
Primary or secondary amenorrhea
- •
Primary and secondary hypogonadism in men
- •
Impaired vision
- •
Prolonged immobilization
- •
Dementia
- •
Excessive alcohol consumption (>2 drinks/day)
- •
Low calcium intake
- •
Recent falls
- •
Poor health/frailty
- •
- •
Trabecular bone in vertebral bodies, the neck of the femur, and the distal radius are most frequently affected by osteoporosis.
- •
Vertebral body fractures are the most common manifestation of osteoporosis, typically presenting with acute onset of severe thoracic or lumbar back pain often with minimal trauma.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
